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City of Geri 11.9ke <br />Heritage ball Received <br />4200 Oitar Lake Road j Gen Lake, VIN 55110 <br />651 14.7-2790/921651-747-2795 (fax} PEAR 11 2021 f <br />E-mail cin`fn--trrmlakgmn.ore <br />Scholarship Award Application CitY of Gem Lak <br />Requlrinents. <br />Currently live in the City of Gem Lake <br />Currently a High School Senior <br />Plense include: <br />0 Completed Application <br />p At. least two. (2) letters bf. reference front School Staff <br />C] Keium to school oliicials by aic third (PI Friday In April of 0duation year <br />0 Mail or bring n. copy to day City. ofGWu Lake,.11etilage Hall, by April 30 orgraduation year <br />A,yn11vant Tnformatfon ii 1 <br />Natne: oI; gin 705C P h . <br />Address: 3 b Z y U f `} pox Zip: -S L - } - -- <br />Sluts: I ' ]�/� t IV Y `1 <br />Data ofBit•[b:, t- Z 5 lt7a% Graduation Year : Z vZ Z ._._... <br />) dtail: D%Lvt • 0,r . ti 5 PlfA2. hl, — r111, <br />Hialt selt22 .[arormation <br />a,.r;*� 1.1igh S61io i1 Pho ie: / (� �� -7 -7 ` 1 i ? <br />iTiglt School: I 1 ~�_.__ <br />A<Itlress: <br />City: ___ _._ stab:• M zip:. <br />Parent(OInformattion <br />fp <br />Parent hFatnc 7 e-ye- Ve"4e y Photte; . V ._- �iy.� — 5L 0 �- <br />7— <br />Address:. -?I Pfn FO <br />City: Ci21�vt Lei Y ___.-- State: ! Z tV Zip: S)10 <br />Lu)ai[: 5-f e V 2 1%Y A; if 5 <br />Parent Na)»c: ����� r'4-1• � I'Itutw 651 1428 <br />Addres <br />City: (�e�'?V1Z�rM N <br />Zip: <br />Email: ✓ter <br />ApplicantSignature: ( Date: 3 % <br />City af0ern L4-e ScltolanbipApplicsfim Psge 16r.4: <br />