Application
PERSONAL INFORMATION
Gender
Date of Birth
Ethnicity
Country of Birth
I am applying to UCLA
Home Telephone Number
Are you a US Citizen?
Cell Phone Number
Other Phone Number
First Name
Primary Email Address
Middle Name
Secondary Email Address
Last Name
Home Address
City
Please Upload Your Photo
County
State
Zip
Do you have any disabilities that you would like to share with us?
(i.e., physical, vision, hearing, learning)
How did you learn about the Jackie Robinson Foundation Scholarship?
LANGUAGE
Language spoken at home other than English.
Please select a second language you speak other than English.
If you speak any languages not listed above, please enter them here:
ACADEMIC INFORMATION
Applicant’s Current School
My High School is:
Location of High School
High School Website
Name of High School
The area which best
describes my high school
is...
High School Address
City
State
Zip
Guidance Counselor’s Name
Guidance Counselor’s Email
What is the total number
of students enrolled in
your high school?
If you attend a school that uses a 5.0 grading scale, please make conversions based on an absolute scale of 4.0.
School Year 2015-16
Unweighted GPA (on an absolute scale of 4.0)
School Year 2015-14
Unweighted GPA (on an absolute scale of 4.0)
School Year 2014-13
Unweighted GPA (on an absolute scale of 4.0)
School Year 2013-12
Unweighted GPA (on an absolute scale of 4.0)
Class Rank
What is the size of your graduating class?
Have you completed any college credits?
Have you completed any AP courses?
Have you completed any college credits?
TRANSCRIPT
Submit an official high school transcript that coincides with the course and grade information provided
Upload Transcript
Submit an official high school transcript that coincides with the grade information provided above. You should upload a PDF of the official
paper transcript issued to you by the registrar at your High School. If the transcript is issued to you in a sealed envelope, it is acceptable for
you to open it for the purpose of uploading.
SCHOLASTIC INFORMATION
TEST INFORMATION
SAT SCORE:
Critical Reading
Writing
Test Date
Total Score
Math
Total Score without Writing
Test Date
Test Date
ACT SCORE
Composite ACT Score Test Date
COLLEGE INFORMATION
Please list the colleges to which you have applied or will apply in order of choice.
First Choice
Location of College
Second Choice
Location of College
Third Choice
Location of College
MAJOR/MINOR
What is your intended major(s)?
What are your intended minor(s)?
What are your professional aspirations?
Are you a first generation college student?
(If either parent/guardian earned at least a four year college degree, answer No)
AWARDS/HONORS
Please indicate if you are being considered for:
Valedictorian
Salutatorian
National Honor Society
List any academic honors you have received in high school.
EXTRACURRICULAR ACTIVITIES
Activity 1
Activity Name
Activity 2
Activity Name
Position(s) Held
Position(s) Held
Description
Description
Begin Activity
Begin Activity
End Activity
End Activity
Activity 3
Activity Name
Activity 4
Activity Name
Position(s) Held
Position(s) Held
Description
Description
Begin Activity
Begin Activity
End Activity
End Activity
If you have participated in academic programs outside of your high school, please list name of program, sponsoring institution, participation
dates and certification, credits awarded (if applicable.)
Have you participated in academic programs
outside of your high school?
Name of Program
Sponsoring Institution
Dates
Certification Credits
Awarded
Have you ever traveled domestically outside your state?
Have you ever travelled internationally?
FINANCIAL INFORMATION
Gross Annual Family Income
How many siblings are 23 years of age
or younger?
How many people currently reside in your
home, including you?
Number of siblings currently attending college
Is this a single or dual parent household?
Were you employed while in high school?
(Includes summers)
SCHOLARSHIPS
Have you applied for/will apply for any of the following scholarships or mentoring programs from any organization other than those offered by
your college or university, including but not limited to:
Coca Cola Scholarship
Church Scholarship
Gates Millennium Scholarship
Ron Brown Scholarship
Hispanic Scholarship Fund
ROTC Scholarship
NAACP College Scholarship
State Scholarship
Point Foundation
Thurgood Marshall Scholarship
Posse Foundation
UNCF Scholarship
Other Scholarship #1
Other Scholarship #2
Other Scholarship #3
FAFSA
Federal Student Aid, a part of the U.S. Department of Education, is the largest provider of student financial aid in the nation.
If you have already filed your Free Application for Federal Student Aid (FAFSA) please upload it below (the preferred method for this
document is a PDF file).
Upload FAFSA Application
HOUSEHOLD 1 (PRIMARY RESIDENCE OF APPLICANT)
Are the applicant’s parents/guardians divorced, separated or otherwise living separately?
Home Address
City & County
State & Zip
Country
PARENT 1/GUARDIAN HOUSEHOLD 1 INFORMATION
Title
Country of Birth
First Name
Ethnicity
Middle Name
Telephone
Last Name
Cell Phone
Gender
Email Address
Relationship to Applicant
Occupation
Is Parent/Guardian a US
Citizen?
What is the highest level of
education Parent/Guardian
1 has achieved?
PARENT 2/GUARDIAN HOUSEHOLD 1 INFORMATION
Title
Country of Birth
First Name
Ethnicity
Middle Name
Telephone
Last Name
Cell Phone
Gender
Email Address
Relationship to Applicant
Occupation
Is Parent/Guardian a US
Citizen?
What is the highest level of
education Parent/Guardian
1 has achieved?
ESSAY QUESTIONS
JACKIE ROBINSON
Jackie Robinson is best known for the courageous role he played in the integration of Major League Baseball in 1947. In fact, Jackie
Robinson exhibited courage and humanitarianism on many fronts overcoming unforeseen barriers and challenges which impacted our
entire social fabric. What kinds of obstacles have you overcome? What can young people learn and take away from a study of the life
of Jackie Robinson?
CURRENT EVENTS
What do you consider to be the most pressing global issue today and why?
LEADERSHIP
Jackie Robinson embodied his statement “A life is not important except in its impact on other lives.” Describe a situation where you took
a leadership role, including why you led the project and how you were effective. How have you personally given back to others?
PERSONAL ESSAY
Write an essay which conveys to the reader a sense of who you are. Possible topics MAY include experiences that have shaped your life,
the circumstances of your upbringing, the way you see the world or any personal theme which appeals to your imagination.
ELECTRONIC SIGNATURE
The electronic signature below and its related fields are treated by the Jackie Robinson Foundation like a physical handwritten signature on a
paper form.
I certify that the information I have provided in this application is complete and accurate and that all statements and
essays are entirely my own work. I understand that my scholarship award may be rescinded should the Jackie Robinson
Foundation determine that I have misrepresented or omitted any material information in my application, or should there
be any material change in my candidacy subsequent to the submission of my application. I hereby authorize all persons or
entities to provide any information that will serve to verify the information I have presented in my application; I expressly
waive any required notice to me. I also understand that if I accept a Jackie Robinson Foundation Scholarship, the
Foundation or its agent may verify information included in my application.
I hereby authorize the Jackie Robinson Foundation to share my application information with scholarship organizations,
foundations and other entities concerned with advancing educational opportunities.
Electronic Signature Date