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The Floyd PFLAG Scholarship is dedicated to celebrating and supporting the continuing education of gay, lesbian, bisexual, transgender students and their allies who exhibit courage and leadership in their schools and communities.  The scholarship is funded by individual donations.

Scholarship Information

The Floyd PFLAG scholarship is in the amount of $1000.  The money must be used for educational expenses.  The award will be distributed to the student upon receipt of a letter of acceptance and/or verification of enrollment.


  • Be a resident of Floyd County, Virginia
  • Be applying to attend a technical/vocational program pursuing certification OR be applying to attend a college or university pursuing an undergraduate college degree
  • Be a self-identified lesbian, gay, bisexual, transgender student or LGBT ally
  • Have demonstrated service or a desire to serve the LGBT community


Your application and required materials are completely confidential.

They must be postmarked or submitted to school personnel by April 15th.

One letter of reference from someone other than a family member.

A signed and completed release form.  A parent or guardian must sign if you are under 18 years of age.



Your high school guidance counselor or administrator.

Floyd PFLAG, P O Box 766, Floyd, VA 24091







Personal Data:


Student’s Name (Print) ___________________________________________________________

Address  ________________________________________________________________

City/State/Zip __________________________________________________________________

Email ____________________________________________

Phone __________________________     Cell ___________________________

Date of Birth ____________________________________________

How do you identify yourself?  (Please check)

____    Lesbian                       ____    Gay                                         ____            Bisexual

____    Transgender                ____    Gender Non-Conforming       ____            Ally


Please complete the following:

Expected Graduation Date ______________________

Name of High School  __________________________________


Name and location of school you are applying to/plan to attend:

Name of School, City, State _______________________________________________________

Name of School, City, State _______________________________________________________

Name of School, City, State _______________________________________________________


What is your admission status?  (Please check)

_____  Planning to apply               _____  Applied and waiting for response   _____ Accepted



Major intended or area of studies: ___________________________________________________


Please list involvements or leadership roles you have had at school and in your community:




Essay:  (Please attach)  Your essay should be between 500 and 1000 words, preferably typed, and should include the following:  How has being an LGBT Student or Ally impacted your life? How have your experiences molded who you are today?  What have you done and what will you do to support the school environment for LGBT students?

I certify that the information contained in this application is true.


Signature ____________________________________            Date: _______

(A release form and one reference must accompany this application.)



Release Form


Please indicate “Grant” or “Do Not Grant” in each line and sign.


Please be assured that whether you grant or deny these permissions, it WILL NOT affect the outcome of your application.


On the _______ day of ____________(month), ________ (year), I make the following statements of my own free will.


Signature of Student: __________________________________


Print Name: _________________________________


Please check as appropriate and sign by each:


___I Grant  ____ I Do Not Grant (sign here: ___________________________________)

to Floyd PFLAG permission to publish an announcement of my scholarship award in the local news media.


___I Grant  ____ I Do Not Grant (sign here: ___________________________________)

to Floyd PFLAG permission to use my photograph in their publicity releases about my scholarship award.


___I Grant  ____ I Do Not Grant (sign here: ___________________________________)

to Floyd PFLAG permission to use my scholarship essay in an anthology of stories to be compiled for publication or for promotion of the scholarship program.


___I Grant  ____ I Do Not Grant (sign here: ___________________________________)

to Floyd PFLAG permission to include my picture and bio in any and all PFLAG media.


Any comments? _________________________________________________________________


*If you are under 18 years of age, your parent/guardian must sign approving your above responses.


Parent/Guardian Signature _____________________________________________


Print Name _____________________________________                      Date___________


Relationship _____________________




Reference Form


Floyd PFLAG is a chapter of a national organization founded in 1972, with approximately 250,000 members and supporters in the United States.  The mission of the local chapter, one of 400 nationwide, is to educate on LGBT issues, support the LGBT community, and advocate for laws and policies which advance and protect equality for all.  Floyd PFLAG is pleased to offer a $1000 scholarship to a graduating high school senior.


You have been given as a reference by: _______________________________________________


Reference Name (please print): ______________________________________________________


Reference Address: _______________________________________________________________


City/State/Zip: ___________________________________________________________________


Phone: ___________________________      Email: ____________________________________


How long have you know this student: _____________________


What is your relationship to this student? (teacher, administrator, minister, counselor, friend, etc.)




Would you recommend this student for the Floyd PFLAG Scholarship – and why?  (Please use a separate sheet of paper if necessary.)










Signature __________________________________       Date ______________________


Please return the completed reference form by April 15th to either:

The high school staff person responsible for scholarships OR

Floyd PFLAG, P O Box 766, Floyd, VA 24091


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