The Forest C. and Ruth V. Kelsey Foundation

The Forest C. and Ruth V. Kelsey Foundation

For Students Graduating from High School

SPRING 2017

Forest and Ruth Kelsey, long time residents of Montesano, established this scholarship foundation to assist students, “who show promise of becoming good citizens and community leaders, and who need financial assistance in the pursuit of education beyond the high school level.” The number and amount of the awards are subject to change from year to year. Applications will be available March 14, 2017

The applicant shall be required to complete the Application form, Anticipated Budget & Expenditures form, and a one-page essay outlining your future career goals. It is also possible that the applicant shall be interviewed by a member of the Selection Committee and this would be arranged with the applicant whenever possible.If you do not include the essay we cannot consider your application.

Applicants awarded scholarships will be notified at graduation or during senior honors ceremony depending on the school’s policy.

Important Note

Only a limited number of scholarships are available so do not delay in returning your applications as they will be reviewed on a first come first serve basis.

Please fill in application, including social security number and contact phone number, clearly and accurately.Please PRINT your e-mail address very clearly as we often correspond via e-mail and you could miss important informationthat could affect receiving your scholarship funds.

MAIL APPLICATIONS TO:

The Kelsey Foundation

P.O. Box 404

Montesano, WA 98563

Applications must be in the Kelsey Foundation Office (120 W Pioneer Ave., Montesano, WA) no later than5:00p.m.April 14, 2017. Incomplete applications or applications received after the deadline will not be considered. Post marked by April 14th does not count. They must be received in the foundation office by the above date and time. No exceptions!

APPLICATION FOR SCHOLARSHIP

High School Graduating Seniors

FOREST C. AND RUTH V. KELSEY FOUNDATION

I hereby make application for a scholarship under the terms and conditions of an Educational Scholarship from the Kelsey Foundation.

NAME AND RESIDENCE: (please print legibly)

1.Name in Full______Age_____SS#______

2.Mailing Address: ______City______Zip_____

Physical Address: ______City______Zip_____

Phone______Current Cell Phone______

Email Address______

3.Which High School do you now attend?______

4.G.P.A. Accumulative?______Rank in Class?______

COLLEGE OR SCHOLASTIC INFORMATION:

5.Are you planning to attend a four (4) year or two(2) year college or a vocational school this fall? Please circle one.

Name of college or school______

6.What curriculum will you be studying?______

______

7.When do you expect to graduate or complete your college course of study?______

______

8.In what school activities, other than the prescribed curriculum, have you participated?______

9.In what outside activities, other than school activities, have you participated?______

______

______

FAMILY BACKGROUND:

10.Name of Father______

Father’s Occupation______

Firm Name and Address______

Phone Number______Cell Phone______

11.Name of Mother______

Mother’s Occupation______

Firm Name and Address______

Phone Number______Cell Phone______

12.If parents are not living, give name and address of guardian or nearest relative.______

______

______

YOUR EMPLOYMENT RECORD:

13.List your work experience:______

______

______

______

______

______

GENERAL INFORMATION

I am using the following as references and I authorize you to contact them directly in connection with my application for this scholarship.

General References (List 2)

NAMEPHONE # BUSINESS POSITION

______

______

Teachers (List 2)

NAME PHONE # POSITION HELD

______

______

In general, do you have any health conditions that would interfere with your college studies?______

I certify to the correctness of the foregoing answers and promise to use the scholarship granted me toward no other than the necessary expenses of securing an education.

UNDER IRS REGULATIONS, IT MUST BE AGREED AND IT IS HEREBY UNDERSTOOD THAT IF ANY RECIPIENT RECEIVES BUT DOES NOT APPLY THE TOTAL AMOUNT OF THE MONEY FOR EDUCATION, THAT THE AMOUNT NOT APPLIED SHALL BE REPORTED TO THE FOUNDATION AND RETURNED. APPLICANT’S SIGNATURE CONSTITUTES AGREEMENT TO ABIDE BY THIS REQUIREMENT, AND THAT DISCLOSURE OF THIS INFORMATION WAS MADE PRIOR TO SIGNING.

Dated______Signed______

KELSEY FOUNDATION SCHOLARSHIP

ANTICIPATED BUDGET AND EXPENDITURES

Full Name______

Full Home Address______

Phone______

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

LIVING EXPENSESESTIMATED FOR ONE YEAR

Room/Board$______

Tuition/Fees$______

Books & Supplies$______

TOTAL EXPENSES$______

______

Signature of ApplicantDate

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