Application for Elinor Shaffer Scholarship for Youthbuild Graduates

Helene D. Stoneman Scholarship

and Civic Leadership Program

2016Application Form

Applications are due MondayNovember 21, 2016

To be filled out by the applicant and the recommending YouthBuild staff person

PERSONAL INFORMATION - Please provide us with your current contact information.

Last Name: ______First Name: ______Middle Initial: ______

Address: ______

City: State: ZIP:

Phone: (_____) ______Email: ______

Gender(optional):___ Female ___ MaleAge (optional): ______

Race (optional):___ African American ___ Asian American ___ Native American

___ White ___ Hispanic ___ Multi-Racial___ Other

YOUTHBUILD PROGRAM STUDENT DATA

Please include a copy of an officialhigh school diploma or its equivalent.

Graduation Date Month ____ Year ______

Date Received DIPLOMA or its Equivalent Month ____ Year ______

GED score (if applicable)______

Community College Admission Test Score or SAT/ACT Score

UNDERGRADUATE AND GRADUATE STUDENT DATA

To be completed by applicants currently in college or graduate study.

Name of College You Attend: ______

City: ______State: ____

___ 2-year Community or Junior College___ 4-year College or University ___ Graduate Study

Year in college or graduate school as of September 2016 __ 1 __ 2 __ 3 __ 4 __ 5 __ Graduate Study

Major or course of study: ______

Current college cumulative grade point average (4.0 Scale): ______

Please include a copy of yourcollege’s official transcript.

Expected date of graduation: ____ Month _____ Year

Degrees Completed

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s ______Other

Date degree received: ____ Month _____ Year

To be completed by applicants who are entering or changing college.

Name of College You Plan To Attend: ______

City: ______State: ____

___ 2-year Community or Junior College___ 4-year College or University ___ Graduate Study

Year in college or graduate school as of September 2015 __ 1 __ 2 __ 3 __ 4 __ 5 __ Graduate Study

Major or course of study: ______

Current college cumulative grade point average (4.0 Scale): ______

Please include a copy of your college’sofficial transcript.

Date of graduation: ____ Month _____ Year

Degrees sought:

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s______Other

Degrees Completed

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s ______Other

Date degree received: ____ Month _____ Year

FINANCIAL INFORMATION
Your Financial Resources

Describe

Scholarships$______

Grants$______

Segal AmeriCorps Ed.Award$______

IDA$______

Educational Loans$______

Personal Savings$______

Family Contributions$______

Other Resources$______

Total Financial Resources$______

Your College Expenses

Tuition ………………………….$______

Room & Board ……………….$______

Other Expenses ………...... $______Describe:______

Total College Expenses…….$______

Your Employment

Are you working or planning to work while going to school? ____ YES____ NO

If YES, please check one:____ part-time____ full-time

Employer:______

Job Description:______

______

Monthly Wages:$ ______

CIVIC ENGAGEMENT ACTIVITIES

Are you or have you ever been involved in any of these civic engagement activities?

(Please check all that apply)

___Voter Registration ___ Political Campaign Work ___ Meeting with Elected Officials ___ Political Rallies

___Other Political Activities ___ Non-YouthBuild Political Activities___ Other

Name of OrganizationCityStateActivities

______

Are you registered to vote? ____ YES____ NO

LEADERSHIP AND COMMUNITY SERVICE ACTIVITIES

Are you or have you ever been engaged in any of these leadership positions?

(Please check all that apply)

___YouthBuild Program Policy Committee ___Young Leaders Council ___National Alumni Council

___YouthBuild Program Board of Directors ___YouthBuild USA Board of Directors

___ AmeriCorps Education Award ___Other YouthBuild Leadership Positions

___ Other Organizations

Name of OrganizationCityStateActivities

______

Have you ever attended any of the following leadership events?

(Please check all that apply)

___ National YouthBuild Conference of Young Leaders ___ Regional YouthBuild Youth Conference

___Other YouthBuild Events___ Alumni Xchange ___ Non-YouthBuild Leadership Events

Please Describe: ______

______

Please describe any other community or volunteer activities you have participated in during the past four years,including year(s) and length of service. Indicate any special awards or honors you have received: