NAME
ADDRESS
PARENT’S NAME(S)
FAMILY INCOME AS SHOWN ON LAST TAX RETURN:
Parent – Please Select One:
0-40,000
$40,000-70,000
$70,000-100,000
$100,000-130,000
Over $130,000
ACTIVITIES
·
LEADERSHIP POSITIONS
RECOGNITION OR AWARDS
(OPTIONAL)
IF THE LIONS CLUB HAD EXTRA FUNDS, WHICH ORGANIZATION, OR CAUSE SHOULD THEY SUPPORT AND WHY?
SCHOOL TO BE ATTENDING
Deadline: April 1
G.P.A
Class Rank
A.C.T.