Keith West Memorial Fund Claim Request Form

Graduated high school students who have been awarded a scholarship through the Keith West Memorial Fund can use this form to submit proof of enrollment and request disbursement of scholarship funds. Scholarship funds will be sent to the registrar.

Scholarship Recipient's Legal Name*
First Last
High School*
State*
Email*
HS Graduation Year*
Proof of college enrollment is required for scholarship disbursement. If you will graduate in 2022 or beyond, please complete this form closer to your graduation date.
College/University Name*
Address of Registrar*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please upload proof of enrollment*
Proof of enrollment should include student name and name of institution.
Drop files here or
College/University Student ID #*
Home Address (optional)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Requirements / Comments (optional)