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First Name

Last Name

Address

Address (ie. Apt #)

City

State

Zipcode

Phone

Date of Birth

High School Name

Location

CUMULATIVE GRADE POINT AVERAGE (which includes 9th, 10th and 11th grade):

Name of Father

Name of Mother

SIBLINGS (Names and Ages)

HIROSHIMA LINEAGE: Name of Hiroshima immigrant related to you

Full name of parent with Hiroshima lineage

Prior or Current Member of SHC? (Y or N)

Yes No

Full name of grandparent with Hiroshima lineage

Prior or Current Member of SHC? (Y or N)

Yes No

Full name of great-grandparent with Hiroshima lineage

Prior or Current Member of SHC? (Y or N)

Yes No

Full name of great, great-grandparent with Hiroshima lineage

Prior or Current Member of SHC? (Y or N)

Yes No

SCHOOL AWARDS AND RECOGNITION:

EXTRACURRICULAR SCHOOL ACTIVITIES:

COMMUNITY INVOLVEMENT AND ACTIVITIES:

NON-SCHOOL AWARDS AND RECOGNITION:

HOBBIES AND INTERESTS:

EMPLOYMENT HISTORY (From grade 9 to date):

Name/Location of Employer

Dates of Employment

Name/Location of Employer

Dates of Employment

Name/Location of Employer

Dates of Employment

COLLEGES AND UNIVERSITIES APPLIED TO:

PROPOSED DEGREE/MAJOR:

FUTURE GOALS AND ASPIRATIONS:

THE FOLLOWING DOCUMENTS MUST ACCOMPANY THE APPLICATION:

1. Senior high school official transcript as of the latest completed semester/trimester.

2. List of current classes and projected second term courses.

3. An essay of 200 words on the subject “What Hiroshima Means to me”.

4. At least two recommendations: one from a school official, and one from a community member.
(Recommendations from relatives will not be accepted.)