Miss Juneteenth America Scholarship Pageantry Program

By typing your name below, you acknowledge that you have read, understood, and agree to the terms above.

Today's Date

Full Name

Parent/Guardian's Street Address

Parent/Guardian's City

Parent/Guardian's State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Parent/Guardian's Zip Code

Parent/Guardian's Phone Number

Parent/Guardian's Email Address

Social Media Profiles(s) (Instagram, Facebook, etc.) (Optional)

Full Name

Date of Birth

Street Address

City

State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Phone Number

Email Address

Social Media Profiles(s) (Instagram, Facebook, etc.) (Optional)

School Name

Current Grade Level 8th9th10th11th12th

Participant's GPA between 2.5 and 3.0between 3.1 and 3.5between 3.6 and 4.0over 4.0 +

Extracurricular Activities

School Involvement

Community Service

Accomplishments/Awards

Career Aspiration Select only one profession.

Hobbies or Talents

Please Select the Participant’s Favorite HBCU or HBCC by First Choosing Its State Select StateAlabamaArkansasCaliforniaDelawareDistrict of ColumbiaFloridaGeorgiaIllinoisKentuckyLouisianaMarylandMichiganMississippiMissouriNew YorkNorth CarolinaOhioOklahomaPennsylvaniaSouth CarolinaTennesseeTexasVirgin IslandsVirginiaWest Virginia

Select Participant's Favorite HBCU or HBCC in Alabama? Select Participant's Favorite HBCU or HBCC in Alabama?Alabama A&M UniversityAlabama State UniversityBishop State Community CollegeGadsden State Community CollegeJ.F. Drake State Technical CollegeLawson State Community CollegeMiles CollegeOakwood UniversitySelma UniversityShelton State Community College - C.A. Fredd CampusStillman CollegeTalladega CollegeTrenholm State Technical CollegeTuskegee University

Select Participant's Favorite HBCU or HBCC in Arkansas? Select Participant's Favorite HBCU or HBCC in Arkansas?Arkansas Baptist CollegePhilander Smith CollegeShorter CollegeUniversity of Arkansas at Pine Bluff

Select Participant's Favorite HBCU or HBCC in California? Select Participant's Favorite HBCU or HBCC in California?Charles R. Drew University of Medicine and Science

Select Participant's Favorite HBCU or HBCC in Delaware? Select Participant's Favorite HBCU or HBCC in Delaware?Delaware State University

Select Participant's Favorite HBCU or HBCC in D.C.? Select Participant's Favorite HBCU or HBCC in D.C.?Howard UniversityUniversity of the District of Columbia

Select Participant's Favorite HBCU or HBCC in Florida? Select Participant's Favorite HBCU or HBCC in Florida?Bethune Cookman UniversityEdward Waters CollegeFlorida A&M UniversityFlorida Memorial University

Select Participant's Favorite HBCU or HBCC in Georgia? Select Participant's Favorite HBCU or HBCC in Georgia?Albany State UniversityClark Atlanta UniversityFort Valley State UniversityInterdenominational Theological CenterMorris Brown CollegePaine CollegeSavannah State UniversitySpelman College

Select Participant's Favorite HBCU or HBCC in Illinois? Select Participant's Favorite HBCU or HBCC in Illinois?Chicago State University

Select Participant's Favorite HBCU or HBCC in Kentucky? Select Participant's Favorite HBCU or HBCC in Kentucky?Kentucky State UniversitySimmons College of Kentucky

Select Participant's Favorite HBCU or HBCC in Louisiana? Select Participant's Favorite HBCU or HBCC in Louisiana?Dillard UniversityGrambling State UniversityNew Orleans UniversitySouthern University and A&M CollegeSouthern University at New OrleansStraight CollegeXavier University of Louisiana

Select Participant's Favorite HBCU or HBCC in Maryland? Select Participant's Favorite HBCU or HBCC in Maryland?Bowie State UniversityCoppin State UniversityMorgan State UniversityUniversity of Maryland Eastern Shore

Select Participant's Favorite HBCU or HBCC in Ohio? Select Participant's Favorite HBCU or HBCC in Ohio?Central State UniversityWilberforce University

Select Participant's Favorite HBCU or HBCC in Michigan? Select Participant's Favorite HBCU or HBCC in Michigan?Lewis College of Business

Select Participant's Favorite HBCU or HBCC in Mississippi? Select Participant's Favorite HBCU or HBCC in Mississippi?Alcorn State UniversityCoahoma Community CollegeHinds Community CollegeJackson State UniversityMary Holmes CollegeMississippi Valley State UniversityMount Hermon Female SeminaryPrentiss Institute Jr. CollegeRust CollegeTougaloo College

Select Participant's Favorite HBCU or HBCC in Missouri? Select Participant's Favorite HBCU or HBCC in Missouri?Harris-Stowe State UniversityLincoln University-Missouri

Select Participant's Favorite HBCU or HBCC in North Carolina? Select Participant's Favorite HBCU or HBCC in North Carolina?Barber-Scotia CollegeBennett CollegeElizabeth City State UniversityFayetteville State UniversityJohnson C. Smith UniversityLivingstone CollegeNorth Carolina A&T State UniversityNorth Carolina Central UniversitySaint Augustine's UniversityShaw UniversityWinston-Salem State University

Select Participant's Favorite HBCU or HBCC in New York? Select Participant's Favorite HBCU or HBCC in New York?CUNY-The Medgar Evers College

Select Participant's Favorite HBCU or HBCC in Oklahoma? Select Participant's Favorite HBCU or HBCC in Oklahoma?Langston University

Select Participant's Favorite HBCU or HBCC in Pennsylvania? Select Participant's Favorite HBCU or HBCC in Pennsylvania?Cheyney University of PennsylvaniaLincoln University-Pennsylvania

Select Participant's Favorite HBCU or HBCC in South Carolina? Select Participant's Favorite HBCU or HBCC in South Carolina?Allen UniversityBenedict CollegeClaflin UniversityClinton Junior CollegeDenmark Technical CollegeMorris CollegeSouth Carolina State UniversityVoorhees College

Select Participant's Favorite HBCU or HBCC in Tennessee? Select Participant's Favorite HBCU or HBCC in Tennessee?American Baptist CollegeFisk UniversityKnoxville CollegeLane CollegeLemoyne-Owen CollegeMeharry Medical CollegeMorristown CollegeTennessee State University

Select Participant's Favorite HBCU or HBCC in Texas? Select Participant's Favorite HBCU or HBCC in Texas?Guadalupe CollegeHuston-Tillotson UniversityJarvis Christian CollegePaul Quinn CollegePraire View A&M UniversitySouthwestern Christian CollegeSt. Phillips CollegeTexas CollegeTexas Southern UniversityUniversity of Texas at El PasoWiley College

Select Participant's Favorite HBCU or HBCC in Virgin Islands? Select Participant's Favorite HBCU or HBCC in Virgin Islands?University of the Virgin Islands

Select Participant's Favorite HBCU or HBCC in Virginia? Select Participant's Favorite HBCU or HBCC in Virginia?Hampton UniversityNorfolk State UniversitySaint Pauls CollegeVirginia State UniversityVirginia Union UniversityVirginia University of Lynchburg

Select Participant's Favorite HBCU or HBCC in West Virginia? Select Participant's Favorite HBCU or HBCC in West Virginia?Bluefield State CollegeStorer CollegeWest Virginia State University

Participant's Favorite Quote

Unsung SheRose™ Black female from the United States that is an Unsung SheRose™ not often discussed and/or as well known to the general public, but information is available via research, including a photo.

Participant’s T-Shirt Size X-SmallSmallMediumLargeX-Large2X-Large3X-Large

Food Allergies or Dietary Needs Peanuts, Shellfish, Gluten-Free, Vegan, Pescatarian, etc.

How do you plan to use any scholarship funds earned? There’s no right or wrong answer — we simply want to know how this scholarship could support your young lady’s goals. Examples: summer enrichment programs, school supplies, college courses, transportation, band camp, leadership training, etc.

Nonprofit Organization of Choice Include the organization’s name, mission, website, and social media profile(s) if available. The nonprofit must have 501(c)(3) designation.

New Field New Field I understand that the non-profit selected must be able to produce a Letter of Determination as provided by the IRS reflecting their 501(c)(3) status.

New Field New Field I will submit a professional headshot by email to admin@ckiniondesign.com following photo guidelines.

New Field New Field I understand this application will be used for the participant’s public bio.

New Field New Field I agree to pay the full registration fee as outlined, and understand that the $50 application fee is non-refundable.

How did you hear about the Miss Juneteenth Scholarship Pageantry Program? Search Engine (Google, Yahoo, etc.)Social Media (Facebook, Instagram, YouTube, etc.)Past ParticipantSchool or EducatorCommunity OrganizationOther