MISS ROME SCHOLARSHIP PROGRAM

APPLICATION and FACT SHEET

FULL NAME: ___________________________________________

HOME ADDRESS: _______________________________________________
SCHOOL ADDRESS______________________________________________

TELEPHONE: (HOME)___________________(SCHOOL)_____________________
E-MAIL ADDRESS__________________________________________
PARENT'S NAME______________________________________
HIGH SCHOOL OR COLLEGE (IF APPLICABLE)_________________________

DATE OF BIRTH:______________________________

TYPE OF TALENT_______________________________
               (dance, vocal, etc.) 

COLLEGE MAJOR:______________________CLASS:______________

MAIL TO:  Andrea Pitts
		14 Arlington Court
		Rome, GA 30165
		(work) 706-368-8380
		(home) 706-295-4325
		(cell) 706-766-4887

OR E-MAIL Andrea.Pitts@HCAHealthcare.com