B Nai B Rith Great Lakes Region

B’nai B’rith Great Lakes Region

2018/2019 College Scholarship Program Application

Student’s General Information
Name: / Date of Birth:
Email Address: / Social Security #:
Home Street Address:
City / State: / Zip Code:
Preferred Phone: / Alternate Phone:
Parent/Guardian #1 Name:
Occupation:
Address if different:
Parent/Guardian #2 Name:
Occupation:
Address if different:
List your sibling’s names, their ages and the college/university’s they are attending:
Sibling #1 Name & Age:
University they are attending, if applicable:
Sibling #2 Name & Age:
University they are attending, if applicable:
Sibling #3 Name & Age:
University they are attending, if applicable:
Financial Information (All questions in this section must be answered)
Parent’s 2017 or 2016 Adjusted Gross Income, if filing jointly (line 37 of Form 1040):
If filing separately, provide father’s 2017 or 2016 Adjusted Gross Income:
If filing separately, provide mother’s 2017 or 2016 Adjusted Gross Income:
Do your parents/guardians have a Michigan Education Trust Account for you?
Do your parents/guardians have a Section 529 Education Savings Plan?
If yes, what is the current value of this account:
Academic Information
Name of your current High School:
High school GPA: / ACT Score: / SAT Score:
List the names of each college that you have applied or plan to apply:
College #1: / College #2:
College #3: / College #4:
List the names of each college that you have been accepted to attend:
College #1: / College #2:
College #3: / College #4:
List the names of colleges in order of your preference to attend and their cost:
Preferred Choice: / Estimated Annual Tuition:
Secondary Choice: / Estimated Annual Tuition:
Academic field of study you intend to pursue and why:
List other scholarships that you have been awarded (provide type of scholarship and the amount):
Personal Accomplishments:
Provide details regarding the information requested below on a separate sheet. Limit response to no more than 100 words for each item below:
Scholastic Achievements: Distinctions, awards and/or honors earned; include the name of each accomplishment, the year awarded, and the name of the institution which recognized you:
Performing Arts Achievements: Activities, awards and distinctions earned; include the name of each activity, the year you participated or received an award and name of the institution which recognized you:
Athletic Achievements: Activities, awards and distinctions earned; include the name of each activity, the year you participated or received an award and name of the institution which recognized you:
Extra-Curricular Activities: Provide details about the activities, clubs, awards and distinctions received as a participant in extra-curricular programs at your school; include the name of each activity, the year you participated or received an award and name of the institution which recognized you:
Volunteer/Community Service Accomplishments:
Provide details regarding the information requested below on a separate sheet. Limit response to no more than 250 words for each item below:
Charitable Organization Achievements: List the charitable organizations where you have volunteered. Describe how your involvement benefited our community, why it was meaningful to you and any awards and distinctions you earned:
Religious Education: Describe your religious education and participation in religious organizations; include the name of the religious institution, the year(s) you participated and any accomplishments you earned:
Other Considerations: Explain any special circumstances, whether financial or otherwise, that the scholarship committee should consider in its evaluation of your application.
Essay Question: (limit your response to no more than 250 words)
If you are awarded the B’nai B’rith Great Lakes Region College Scholarship, how would you pay it forward so that our community benefits from our investment in you?
Important Notice, Terms and Conditions:
B’nai B’rith pledges to protect the privacy rights of the applicants and their families. Please be assured that this application as well as all other documentation that is collected in the course of the scholarship process will not be shared with any agency or individuals, other than with the members of the B’nai B’rith Great Lakes Region Scholarship Selection Committee. All applications and other documents submitted by the applicants will be shredded and discarded on the business day following the awards ceremony with the exception of applications and documents of the students who are awarded scholarships, which will be retained by B’nai B’rith.
In applying for this scholarship, the applicant and his/her family understands that all decisions of the Scholarship Committee are final and further agrees to hold harmless B’nai B’rith International, the B’nai B’rith Great Lakes Region, members of the Scholarship Programand the Selection Committee for its decisions.
The successful students who are awarded scholarships also agree to permit B’nai B’rith Great Lakes Region to use their name, photographs and other identifiable images of them for the sole purpose to promote and publicize the scholarship program in various media channels.
BEFORE SENDING, PLEASE MAKE SURE YOU HAVE ALL OF THE REQUIRED DOCUMENTS:

A completed B’nai B’rith Great Lakes Region (BBGLR) College Scholarship Application

First two pages of the Parent’s/Guardian’s 2017 (2016 if they have not filed 2017 yet) Federal Income Tax Form 1040
Most current High School transcript
ACT and/or SAT transcript

Acknowledgement of Acceptance of Scholarship Program Terms and Conditions:
The undersigned agree to the terms and conditions of the B’nai B’rith Great Lakes Region College Scholarship Program noted above and attest that they have made a good faith effort to provide the Scholarship Committee will accurate and truthful information.
Signature of Applicant: / Date:
Print Name of Applicant:
Signature of Applicant’s Parent/Guardian: / Date:
Print Name of Applicant’s Parent/Guardian:
Date Received by BBIGLR Scholarship Committee: / Date:
BBIGLR Scholarship Committee Member Name: