WEMBACK Scholarship Application Form

We Empower Minds, Building Access, Community, Knowledge

SECTION 1 – Applicant Information

First Name

Last Name

Preferred Name (if different)

First Name

Last Name

Phone/Mobile

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Current School Name

Current Grade or Year in School

11th

12th

College – 1st Year

College – 2nd Year

Are you currently enrolled full-time?

Yes

SECTION 2 – Eligibility Confirmation

Do you identify as a Black/African-descendant student (African American, Afro-Caribbean, African diaspora, etc.)?

Yes

Are you currently attending or accepted into a 2-year or 4-year college, university, or accredited program?

Yes, currently attending

Yes, accepted and will attend

Not yet

What type of institution are you attending or planning to attend?

2-year community college

4-year college/university

Trade/technical school

SECTION 3 – Academics & Activities

Current GPA (unweighted, if possible)

List any honors, awards, or recognitions you have received (if any).

List your extracurricular activities, community involvement, jobs, or leadership roles. Include school clubs, work experience, church/community groups, volunteering, family responsibilities, etc.

SECTION 4 – Short Essay

Essay Question (300–500 words)

How have you empowered your community, and how do you hope to use education to continue that work?

SECTION 5 – Documents Upload

Upload your most recent transcript or report card.

Choose File

Upload one letter of recommendation. The recommendation can be from a teacher, counselor, mentor, coach, supervisor, or community leader who knows you well.

Choose File

Upload proof of enrollment or acceptance. Acceptance letter, student ID, or enrollment verification.

Choose File

If you do not yet have proof of enrollment, please explain your current status and expected timeline.

SECTION 6 – WEMBACK™ Legacy Questions

What does “legacy” mean to you?

SECTION 7 – Consent & Verification

Permission to Share. If selected, I give permission for my name, photo, and a brief description of my story to be shared in WEMBACK Scholarship communications (website, social media, printed materials).

I agree

I do not agree

Certification Statement

I certify that the information in this application is true and complete to the best of my knowledge. I understand that providing false information may disqualify me from consideration.

I agree

Electronic Signature (Type your full name)

Date / Time

Parent/Guardian Consent Section (Required for Applicants Under 18)

First Name

Last Name

Parent/Guardian Email Address

Parent/Guardian Phone Number

I am the parent or legal guardian of the applicant named above. I grant permission for my child to apply for the WEMBACK™ Scholarship Fund. I understand that their information may be used for application review and award processing. If my child is selected, I consent to their name, photo, and academic information being used in WEMBACK announcements, unless I request otherwise in writing.

I agree and give consent.

Parent/Guardian Electronic Signature

Date / Time

WEMBACK™ Scholarship Application Form

We Empower Minds, Building Access, Community, Knowledge

SECTION 1 – Applicant Information

Preferred Name (if different)

SECTION 2 – Eligibility Confirmation

SECTION 3 – Academics & Activities

SECTION 4 – Short Essay

Essay Question (300–500 words)

SECTION 5 – Documents Upload

SECTION 6 – WEMBACK™ Legacy Questions

SECTION 7 – Consent & Verification

Certification Statement

Parent/Guardian Consent Section (Required for Applicants Under 18)

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