Daniel Distefano & Michael Western Scholarship 

First Name: ______________________________  Last Name: _____________________________  Street Address: ________________________________________________________________________ 

City, State, Zip code: _____________________________________________________________________________________ 

Phone Number: (___) __________________________   Email address: __________________________ 

School:    _____Smithtown West      _____Smithtown East    

Student information 

Smithtown High School Seniors

 Tell Us about Yourself Extracurricular Activities:                                                                                    ________________________________________  _______________________________________ 

________________________________________  _______________________________________ Awards:                                                                                       ________________________________________  _______________________________________ 

________________________________________  _______________________________________ Memberships‐ Activities/Clubs :  

________________________________________  _______________________________________ ________________________________________  _______________________________________ Other Accomplishments : __________________________________________________________________________________________________________________________________________________________________________ 

Essay Requirements In two or three paragraphs (size 12 font), please respond to the following:  In your estimation, what exemplifies good character, and how have you demonstrated this? 

This  scholarship offers finacial assistance to qualifying Smithtown seniors pursuing college in the fall.

Eligibility: 

GPA: _________