Scholarship Application

Check the school year for which you are applying:*
- 2021-2022
- 2022-2023
Applicant Information
Name
First Last
Age
SSN or ASU Mid-South ID#
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Home Phone
Cell Phone
Are you a U.S. citizen or permanent resident alien?

Applicant Questions
Please answer these questions completely. All incomplete applications will be discarded.
Have you Graduated from High School?*
If NO are you a senior?
Name of High School
Are You Employed?*
Number of Hours Worked
Are you an employee or dependent of an employee of Southland Gaming and Racing?*
Who is employed by Southland Gaming?
Are you a parent?*
(child lives with you, and you/spouse provide more than 1/2 the total support)
Are you a single parent?
(child lives with you, and you provide more than 1/2 the total support)
Some scholarships offer preference to students with disabilities. Would you like to be considered for these?
By selecting “Yes,” you understand written verification from a physician or social services provider may be required.

Foundation Essay?*
Please Upload Your Essay File!
Max. file size: 128 MB.
Without an essay, your scholarship application will only be looked at for Academic Scholarships.
Name*
First Last
Date*
MM slash DD slash YYYY
Certify Your Application*
- I agree
I certify that the information on this application is correct. Should I be awarded this scholarship, I agree to give strict attention to my studies and to the regulations of ASU Mid-South. ASU Mid-South is authorized to make this information available to scholarship donors and scholarship committees. I grant ASU Mid-South permission to release information from my acaemic records to document my eligibility for the award. I also agree to the use of my name, picture, and essay, if required, for news releases should I receive the scholarship. I agree to be present at the annual Foundation Scholarship Luncheon should I be awarded a Foundation scholarship. I understand any award offer is conditional to my meeting eligibility requirements and the continued availability of donor funds which may be revoked with or without notice at the donor’s discretion.
Signature*

Applicant Information