Leadership Initiative Scholarship Recommendation

Referrer Information
Your Name*
First Last
Church or school*
Position*
Primary Phone Number*
Cell Phone Number
If different from primary phone
Email*

Providing your email permits SSI to send periodic updates unless you opt to unsubscribe. All personal information is used solely by Student Statesmanship Institute and our partner organizations, and will not be released, rented, sold, or otherwise distributed to anyone at any time for any reason.
Student Information
Name*
First Last
Phone*
Email*
Parent(s)/Guardian(s) Name*
Parent/Guardian Email*

SSI
4407 W. St. Joe Hwy.
Lansing, MI 48917

Phone: 517-321-6233

Email: ssi@ssionline.org

Referrer Information