Thomasina Williams Memorial Scholarship Application

Part A: Applicant's Personal Data

Full Name *

Date of Birth *

Last 4 Digits of SSN *

Sex *

Age *

Email *

Address *

Apartment/Unit

City *

State *

Zip Code *

Home Phone

Cell Phone *

Parent/Guardian Name(s) *

Part B: Educational Background

Name of High School *

Name of College/University you will be attending in Fall 2026 *

College City *

College State *

Intended Major(s) *

Part C: Extracurricular Activities, Community Service and Honors

Extracurricular Activities *

Community Service *

Honors and Awards *

Part D: Applicant's Checklist

I am of African American descent.

I am a 2026 Staten Island, New York graduating senior.

High School transcript verifying GPA of at least 2.5 (C+)

College acceptance letter.

I have an IEP

Two letters of recommendation from one of the following institutions: Community organization, Academic institution, or Faith based organization

Complete application form, answer all questions, and include all attachments.

My Personal History (75 words minimum) *

0 words

Essay Topic *

Essay (150-500 words) *

0 words

PLEASE NOTE

All 2026 Staten Island, New York graduating seniors may apply. Applications that are incomplete or missing any requested documentation will not be considered.

Deadline: May 1, 2026

Required Document Uploads

High School Transcript *

📎 Click to upload transcript (PDF, DOC, DOCX)

Must show GPA of at least 2.5 (C+)

College Acceptance Letter *

📎 Click to upload acceptance letter (PDF, DOC, DOCX)

Letter of Recommendation #1 *

📎 Click to upload first recommendation letter (PDF, DOC, DOCX)

From community organization, academic institution, or faith-based organization

Letter of Recommendation #2 *

📎 Click to upload second recommendation letter (PDF, DOC, DOCX)

From community organization, academic institution, or faith-based organization

Part E: Certification and Authorization Release

I hereby certify that all information in this application is true and accurate. I am aware that any misrepresentation in this application will result in the disqualification of my application. I give the Harriet Tubman Purple Hat Society, Inc. Scholarship Committee permission to release my transcripts, letters of recommendation and application to scholarship donors and to publicize my scholarship award if I am a recipient.

Applicant's Name (please print) *

Applicant's Signature *

Date *

Parent's Signature *

The Thomasina Williams Memorial Scholarship Award

Part A: Applicant's Personal Data

Part B: Educational Background

Part C: Extracurricular Activities, Community Service and Honors

Part D: Applicant's Checklist

PLEASE NOTE

Required Document Uploads

Part E: Certification and Authorization Release