Grinnell Mutual Road to Success Scholarship Program
Complete the form to enter
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*Student's name:
*Student’s address:
*Student's city:
*Student's state:
Select one
Illinois
Indiana
Iowa
Minnesota
Missouri
Nebraska
North Dakota
Ohio
Oklahoma
Pennsylvania
South Dakota
Wisconsin
*Student's ZIP:
*Student's phone:
*Student’s email:
*Parent/guardian name 1:
Parent/guardian name 2:
*High school name:
*High school address:
*High school city:
*High school state:
Select one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*High school ZIP:
*High school phone:
*Graduation date:
*High school cumulative: GPA
3.0-3.5
3.6-4.0+
What is the date and time for your school's scholarship award ceremony?
*GMRC auto policy #:
*Auto policyholder name:
*Grinnell Mutual agent’s name:
*Agency's name:
*Agency’s address:
*Agency’s city:
*Agency's state:
Select one
Illinois
Indiana
Iowa
Minnesota
Missouri
Nebraska
North Dakota
Ohio
Oklahoma
Pennsylvania
South Dakota
Wisconsin
*Agency's ZIP:
*Agent’s phone:
Agency #:
*Post-secondary school:
*Post-secondary school city:
*Post-secondary school state:
Select one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Current report card or transcript: (PDF / JPG) Please include your first and last name in the filename.
How did you hear about this scholarship?
Agent
Online ad
Website
Other
If other, describe:
I certify I am a high school senior in good academic standing. I am listed as a driver on a Grinnell Mutual, Grinnell Select, or Grinnell Compass auto policy and have no moving violations or accidents on my driving record.