Scholarship Information Form

Congratulations on receiving the Derek Prescott Memorial Scholarship. Your scholarship will be funded directly to the school of your choice. Please provide us with the following information to ensure the correct placement of your scholarship funds. Return this completed form NO LATER than June 13th by completing the form below.

If you cannot complete the form, you can download it and email it to info@derekprescottfoundation.com. This form must be completed to guarantee your funds are received by the start of school. IF THIS FORM IS NOT RETURNED BY THE DEADLINE, YOU WILL NOT RECEIVE FUNDING.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

College Information

College Name

Financial Aid Office Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Financial Aid Office Phone Number:

(###)

###

####

Student ID Number:

VERY IMPORTANT --- TO ENSURE PROPER CREDIT OF FUNDS

If you have any questions on the funding of your scholarship, please contact Nikki Prescott at 970-371-1798 or email info@derekprescottfoundation.com. If you have issues with the online form, you can download and email the from.

Download PDF Form

Please only download and email the form if you are unable to submit the web form.