SRC Foundation Summer Scholarship Application

Canton Community College/Spoon River College
Alumni Association

Full Name

First

Last

Maiden Name

Years Attended

and/or

Graduation Year

Mailing Address

City

State/Province

Zip/Postal

Is this a new address?

Yes

No

Home Phone

Email

HomeHome

WorkWork

Marital Status

Is your spouse/domestic partner also a CCC/SRC Alum?

Yes

No

If Yes, Spouse/Partner Years Attended and/or Grad. Year

Spouse/Partner Full Name

First

Last

Maiden Name

Employer

Title/Position

During your time at CCC/SRC, in what activities were you involved? (Check all that apply.)