KEYPORT INDIANS INC.

ACHIEVEMENT AWARD

PART 1 – PERSONAL INFORMATION
NAME AGE BIRTH DATE SOCIAL SECURITY NO.

 

 
ADDRESS MUNICIPALITY ZIP CODE

 
PHONE NO. E-MAIL ADDRESS

 
PART 2 – PRELIMINARY SCHOOL INFORMATION
NAME OF CURRENT HIGH SCHOOL

 

 GRADUATING YEAR OVERALL GPA
SCHOOL ADDRESS MUNICIPALITY ZIP CODE

 
PHONE NO. GUIDANCE COUNSELOR
NAME OF COLLEGE/UNIVERSITY/TECHNICAL SCHOOL YOU PLAN TO ATTEND

 

 

 
PART 3 – POP WARNER VERIFICATION
NAME(S) OF POP WARNER ORGANIZATION THAT YOU PARTICIPATED IN PRIOR TO HIGH SCHOOL YEARS YOU PLAYED FOOTBALL YEARS YOU WERE A CHEERLEADER

 

 

 

 
DID YOU CONTINUE PARTICIPATING IN POP WARNER WHILE IN HIGH SCHOOL AS A VOLUNTEER?

 

 

 NUMBER OF YEARS AS A VOLUNTEER NUMBER OF HOURS WORKED PER WEEK

***VERY IMPORTANT***

YOU MUST OBTAIN THE VERIFICATION FROM A CURRENT MEMBER OF THE KEYPORT INDIANS. IF YOU NEED ASSISTANCE CONTACT COLLEEN DIPOALO, SCHOLASTIC CHAIRPERSON AT (732) 673-8276

 I hereby certify the information given regarding any Pop Warner involvement, to be true, to the best of my knowledge and belief and in accordance with Franchise records.

KEYPORT INDIANS CORPORATE MEMBER

Signature______________________________

Print Name____________________________

Title___________________________________

KEYPORT INDIANS, INC.

P. O. BOX 838

KEYPORT, NJ 07735

 

1. Applicant must be a permanent resident of Keyport or Union Beach at time of graduation.

2. Applicant must be a high school senior and intends to continue his or her education at a college, university or technical school.

3. Applicant must have been registered and an ACTIVE participant in Pop Warner (i.e., Football, cheerleading, etc.) for at least one full year.

4. Applicant must have a minimum of (2) two years volunteer work in Pop Warner.

5. Applicant must have a GPA of 70 or better.

6. Applicant must submit two letter of personal references (please do not use family members.

7. Achievement Application must be signed by parent/guardian, Guidance Counselor, Corporate Member and student by deadline of application.

8. Applicant must complete the attached Achievement Application in its entirety.

9. Keyport Indians, Inc. reserves the right to modify/waive the criteria if deemed appropriate and/or special circumstances.

PART 4:
Activity/

Category

 Grade Level in year of participation Approx. # of hours spent per week and # of weeks involved Position Held or Honors won Verification by school official
               
POP WARNER

DEMONSTRATOR

COACH

VOLUNTEER

 9 10 11 12      
               
               
               
               
               
               
               
               
INDIVIDUAL SCHOOL HONORS AND AWARDS              
               
   

 

            
   

 

            
   

 

            
   

 

            
   

 

            
               
SCHOOL COMMITTEES, CLUBS, ORGANIZATIONS              
               
   

 

            
   

 

            
   

 

            
   

 

            
   

 

            
   

 

            

 

 

PART 5 – ESSAY (Please type)

Each applicant MUST submit a 150 – 250 word essay on the topic ‘WHAT IMPACT DID KEYPORT POP WARNER HAVE ON MY LIFE". You may start your essay here and if necessary, use a separate sheet of paper and attach to this application

 

PART 6 –

APPLICANT, PARENTS AND SCHOOL OFFICIAL MUST READ AND SIGN.

By way of subscribing our signatures below, we hereby certify, individually and collectively that all of the information contained in this application is true, correct and complete in all its particulars to the best of our knowledge and belief. We understand that this application is filed jointly by all signatories. We agree to give proof of the information provided on this application and realize that if said proofs are not provided that the applicant (student) can be denied any achievement funding. I also understand that The Keyport Indians Inc. reserves the right to modify/waive the criteria if deemed appropriate and/or special circumstances. I further understand that the decision solely belongs to the Keyport Indians Inc. and that all decisions are final. Finally, I the applicant agree to return all money received if I do not attend College of school.

 

Date: ________________________________________________

Signature of Student/Applicant

 

Date: ________________________________________________

Signature of High School Official

 

 

Date: _________________________________________________

Signature of Parent

**Any Questions Please Contact Colleen DiPoalo at (732) 673-3276**

PLEASE MAIL COMPLETED APPLICATION TO:

KEYPORT INDIANS INC.

P.O. BOX 838

KEYPORT, NJ 07735

DEADLINE FOR SUBMISSION IS: May 31, 2008