Qualtrics Survey | Qualtrics Experience Management

First Name

Last Name

WSU ID Number

WSU Email Address

Hometown

Have you completed the WSU general scholarship application for this academic year?

yes
no

Are you in good academic standing with WSU?

No
Yes
Unsure

Will you be enrolled in class full time this academic year?

Yes
No

What year in school are you currently?

What is your area of study?

Please write a few paragraphs about your involvement with WSU or your home community. For example what clubs or organizations are you involved with? Do you have any leadership roles? Why are you involved? What else could you share about yourself and your leadership?

Short Bio about yourself (hometown, major, what your studying, future plans, just little information about yourself)

Are you an enrolled member or descendant of a federally recognized Tribe?

yes
no

If yes, what is your Tribal affiliation

Documentation Please provide proof of tribal enrollment or descendancy (i.e. copy of enrollment card, certificate of degree of Indian blood):

Please provide a headshot. If selected for the scholarship this will be shared with the donor.

Consent Form

If selected for this scholarship, I hereby grant permission to Washington State University (WSU) to use of my name and pertinent information including but not limited to tribal affiliation, major, year in school, hometown, and comments from my application/profile for WSU publication or promotional purposes in any medium including but not limited to print media, newspaper, television, video, motion picture, or website. I grant permission to WSU to release this information to scholarship donors, scholarship trustee, tribal education departments, WSU Native American Advisory Board, Tribal Liaison Newsletter, University communication offices, WSU Foundation, high school counselors, and other entities related to WSU and the scholarship program. I understand that consent to use of my name and pertinent information related to being a scholarship recipient is not a condition of receiving the Scholarship and that consent can be refused without any impact in my ability to fully participate in the program. No inducements or promises beyond my acceptance of an opportunity to promote WSU and its programs have been given to me. Any other use of the above specified information not related to the Scholarship requires advance permission. I understand that I can revoke this consent at any time upon notice to WSU, at which time I will sign a copy of the denial (below). Please check the appropriate box below:

yes
no