Student Name (First, Middle, Last)
Student Address
Student City
Student State and Zip Code
Student Email:
Phone (Home)
Phone (Cell)
High school attended
Reference #1 name and title: High school academic achievements reference (administrator, teacher, or guidance counselor)
How do you know Reference #1?
Reference #1 phone number
Reference #2 name and title: Community leader who has personal knowledge of your community activities and participation
How do you know Reference #2?
Reference #2 phone number
Reference #3 name and title: Teacher, adviser/coach, or employer who can attest to your leadership and entrepreneurial potential
How do you know Reference #3?
Reference #3 phone number
List your most notable activities, work, and community service experience. (Please type no less than 5 achievements in a Word document and then copy and paste it into the box.)

By clicking on the "Submit Form" button below, I certify that I am a resident of Schuylkill County, and do hereby apply for the Wylonis Scholarship Award for the 2015-2016 academic year. I fully understand that any scholarship granted to me is not a vested right binding upon the donor or the Pennsylvania State University, and that the scholarship may be revoked should I fail to continue as a student at the Pennsylvania State University or fail to continue to meet the standards established for this scholarship program.

By clicking on the "Submit Form" button below, I confirm the accuracy of the information contained herein as well as my understanding of the conditions of this scholarship program and my acceptance of them.

This publication is available in alternative media on request. The University is committed to equal access to programs, facilities, admission, and employment for all persons. It is the policy of the University to maintain an environment free of harassment and free of discrimination against any person because of age, race, color, ancestry, national origin, religion, creed, service in the uniformed services (as defined in state and federal law), veteran status, sex, sexual orientation, marital or family status, pregnancy, pregnancy-related conditions, physical or mental disability, gender, perceived gender, gender identity, genetic information, or political ideas. Discriminatory conduct and harassment, as well as sexual misconduct and relationship violence, violates the dignity of individuals, impedes the realization of the University’s educational mission, and will not be tolerated. Direct all inquiries regarding the nondiscrimination policy to Dr. Kenneth Lehrman III, Vice Provost for Affirmative Action, Affirmative Action Office, The Pennsylvania State University, 328 Boucke Building, University Park, PA 16802-5901; Email:; Tel 814-863-0471. U.Ed. SLO 15-22