HARLEM SCHOLARSHIP FOUNDATION
#1 Huskie Circle, Machesney Park, IL 61115 (815) 654-4511
APPLICATION DEADLINE: MARCH 1
The Harlem Scholarship Foundation was established to award scholarships to Harlem High School graduates wishing to continue their education at a vocational school or college/university. A wide variety of scholarships with varying conditions and qualifications are administered by The Harlem Scholarship Foundation.
The Board of Directors strives to award as many scholarships as possible, ranging in value from
$500 to $2,500. Awards are granted primarily, but not solely, on the basis of financial need. The selection committee will consider the applicant’s educational goals as well as his/her financial and academic preparation, planning, and desire to achieve those goals. Some scholarships permit the recipient to re-apply the following year.
ELIGIBILITY CHECKLIST:
Must be current or past graduate of Harlem High School.
Information requested must be typed and accurate. All sections must be completed.* Please indicate N/A if item does not apply.
Application must contain signature of student, parent/guardian and counselor.
High school transcript must be attached.
College students need to submit their college transcripts.
Attach copy of parent(s)/guardian(s) 2016 Federal Income Tax Returns or 2016 W-2 or 1099. The return must be signed by the parent(s)/guardian(s) listed on the tax return.
All bank account numbers and bank routing should be blackened out.
All social security numbers on the tax return should be blackened out.
The Counselor Information Statement must be complete and contain signature of counselor.
All documents must be submitted in a sealed envelope with the student’s signature written across the seal of the flap.
Note: Any application not complying with the above criteria will be designated “incomplete” and will thus be ineligible for scholarship consideration.
DEADLINE FOR APPLICATION: MARCH 1
All applications must be returned to the Harlem High School Guidance Office.
HARLEM SCHOLARSHIP FOUNDATION APPLICATION
Note: ALL information requested is important for processing the application. Applications will be kept confidential. Fields will expand as you type.
1.) APPLICANT INFORMATION
Name: Phone:
Address:
City: State: Zip:
Birth date:
Applicant’s marital status: Single Married
2.) APPLICANT’S FAMILY INFORMATION
A) Father’s/Guardian’s Name: Age:
Address:
City: State: Zip:
Employer: Annual Income:
B) Mother’s/Guardian’s Name Age:
Address:
City: State: Zip:
Employer: Annual Income:
Parents’ current marital status (check one):
Married
Father Deceased
Separated
Mother Deceased
Divorced
C) Other family members at home: Complete for each dependent supported by your parents/guardians.
NAME AGE SCHOOL ATTENDING TUITION/FEES
1.)
2.)
3.)
3.) List schools you are considering (in order of preference.) Check appropriate column. Indicate approximate cost at each institution. Include ONLY tuition and room and board.
SCHOOL TUITION ROOM/BOARD
1.
_____ In-State _____ Out-of-State _____Public _____ Private
2.
_____ In-State _____ Out-of-State _____Public _____ Private
3.
_____ In-State _____ Out-of-State _____Public _____ Private
4.) How do you intend to finance your college education?
a. Parent’s/Guardian’s contribution: $
b. Personal contribution: $
c. Other (explain) $
d. Financial Assistance (Scholarships, grants, etc.)
Source Amount expected Amount received
1
2
3
5.) Parent/Guardian Income Tax Form: Attach your 2016 copy. All returns will be kept confidential. (Please be sure to sign your tax return.)
6.) What field of interest you plan to study/pursue.
7.) List the job, school, and community activities in which you have participated and indicate your level of leadership involvement. The textbox will expand.
8.) If there are any special or unusual circumstances that you would like the committee to take into consideration, please indicate at this point. The textbox will expand.
Please respond to any two of the following questions: Use the space below for your two responses. Please be sure to answer your responses under the appropriate questions. The textboxes will expand.
9.) What one decision in your life has had the greatest impact?
10.) Select one of your activities or interests at Harlem High School or in the community and describe your participation focusing on the difference it has made in your life and in the lives of others.
11.) What person has been the biggest influence in your life? Please explain.
The information, including financial, presented on this application is, to the best of my knowledge, accurate and
up-to-date. If I am selected as a recipient, I hereby give my permission to the Harlem Scholarship
Foundation to use my name, picture, narrative, and the fact that I was awarded a scholarship for promotional purposes.
Student Applicant Date Parent/Guardian Date
The Harlem Scholarship Foundation
Counselor Information Statement
Note: Current college students need not complete this form. Simply attach a recent college transcript to your application.
Applicant’s Name:
1. Accumulated Grade Point Average:
2. Attendance Pattern:
3. High School Attitude Scores:
4. Attach Harlem transcript:
5. Year of Graduation:
6. ACT/SAT Score (Mandatory)
Optional: If there are any special circumstances you wish to share with the committee regarding this applicant, please do so at this time.
Signature of Counselor Date
Deadline: March 1 – Applications must be in Guidance Office