APPLICATION DEADLINE: APRIL 13, 2004 by 3:00 P

(Click on pull-down menu. Be sure you do not list more than one scholarship. One should have scholarship name and the other two should be N/A.)

Scholarship Group (1)

N/AOFFICE COPY1) ALFRED ERK2) SOUTHBURY POLICE LEGAL3) CAROL MEIER4) CRAIG ZALOUMIS5) SOUTHBURY POLICE COMMUNITY ACTION9) JOSEPH P. SHANAHAN ii MEMORIAL SCHOLAR10) LAKE QUASSAPAUG SCHOLARSHIP13) DANIELLE JONES MEMORIAL SCHOLARSHIP14) MIDDLEBURY VOL. FIRE DEPT. 15) POMPERAUG ASSOC EDUCAT. PERSONNEL17) POMPERAUG EDUCAT. ASSOC.18) POMPERAUG HS PTO SCHOLARSHIP19) SAMUEL J. DEPIETRO MEMORIAL SCHOLAR20) SHAWN REEDER MEMORIAL SCHOLAR21) SOUTH. BUS. ASSOC. EDWARD & BEA TAPPE22) SOUTHBURY BUS. ASSOC. (1)24) SOUTHBURY KNIGHTS OF COLUMBUS26) PANTHER AQUATIC CLUB SWIM SCHOLAR28) SOUTHBURY MIDDLEBURY FOUNDATION32) FIELD HOCKEY SCHOLARSHIP34) DELMONT & ELFRIEDE PFEFFER37) D'ANGELO MUSIC AWARD38) GEORGE & ELEANOR TOMEY MEMORIAL SCHOLAR

Scholarship Group (2)

N/A43) UCC POPE EDUCATIONAL SCHOLARSHIP44) PHYS THER & SPORTS MED CTR OF SOUTHBUR SCHOLAR46) SOUTHBURY WOMEN'S CLUB70) NEIL M. LINDENMAN MD MEMORIAL75) DRS. LAROSA AND MARSHALL SCHOLAR FUND 76) REGION 15 BEFORE AND AFTER SCHOOL PROG SCHOLAR78) ADAM HAMAD MEMORIAL SCHOLAR82) SOUTHBURY LAND TRUST-GERALD IVERS85) BECKY CHAPLINSKI MEMORIAL SCHOLARSHIP87) MIDDLEBURY CONGREGATIIONAL CHURCH SCHOLAR89) JOHN MUDRY SCHOLARSHIP94) PHS SOCCER BOOSTER CLUB SCHOLAR100) NEWTOWN SAVINGS BANK FOUNDATION111) SOUTHBURY WOMEN'S CLUB ENRICH SPEC ED SCHOLAR112) PHS SOFTBALL SPORTSMANSHIP SCHOLAR113) PHS SOFTBALL LEADERSHIP SCHOLAR120) FRIENDS OF SOUTHBURY PUBLIC LIBRARY122) SOUTHBURY SOCCER201) PHS POP WARNER SCHOLARSHIP202) RATHSKELLER RESTAURANT208) TUCKER GOWEN SCHOLARSHIP FUND300) KING SOLOMON'S MASONIC LODGE #7301) JAY HARPER MEMORIAL BASKETBALL SCHOLAR302) SUSAN CAVANAUGH MEMORIAL SCHOLARSHIP

Scholarship Group (3)

N/A303) POMPERAUG THEATRE SCHOLARSHIP304) POMPERAUG GRID IRON SCHOLARSHIP329) VETERAN OF FOREIGN WARS POST 1607330) SOUTHBURY WOMEN'S TRADE/APPRENTICE SCHOLAR401) MIDDLEBURY KNIGHTS OF COLUMBUS 3992 SCHOLAR402) AMERICAN LEGION POST 147403) MIDDLEBURY SOCCER ASSOCIATION SCHOLARSHIP

APPLICATION DEADLINE: March 22, 2017 by 2:30 p.m.

REGION 15

SCHOLARSHIP APPLICATION

IDENTIFICATION PAGE

Check scholarships for which you are applying. Be sure you have thoroughly read the descriptions and eligibility for each and verified that you qualify.

A separate application must be turned in for each scholarship to which you apply.

Student Name: / Student ID #:
Social Security / -- / Sex: / FemaleMale / Birth Date: / //
Street:

Town: SouthburyMiddlebury E-Mail Address

Phone Number: / ()- / High School: / Pomperaug High School

Please note information about guardians with whom you reside:

Guardian's full name:

(Please indicate relationship): MotherFatherStepfatherStepmotherGrandparentOther

Guardian's full name:

(Please indicate relationship): MotherFatherStepfatherStepmotherGrandparentOther

*Signatures at bottom verify all application information is true.

Student: / Date:
Parent: / Date:

PAGE -2-

PERSONAL INFORMATION PAGE

(Use separate sheet if necessary, with your Social Security # on each page.)

(unweighted) GPA: / **SAT HIGH SCORES: / R / M / W

**SAT highest scores in each test

ACT Composite Score:

Academic Honors received in high school: (include year received)

PHS Extracurricular Activities (school related) (put an X in the grade box)

Activity / 9 / 10 / 11 / 12 /

Hrs/wk

/ # of wks / Special Involvement

Athletic Participation (in and out of school) (put an X in the grade box)

Sport / 9 / 10 / 11 / 12 / Special Achievement

Community Involvement (put an X in the grade box)

Activity / 9 / 10 / 11 / 12 / Hrs/Yr

Work Experience

List any job (including summer employment) you have held during the past three years.

Specific Nature
of Work / Employer / Approximate Dates
Of Employment / Approximate Number of
Hours Spent Per Week

College/University (you are planning to attend and for which aid is requested)

SCHOOL NAME / CITY / STATE / ZIP CODE
Intended Major:
Career you plan to pursue: /
Have you received an acceptance? / YesNo
Put an X for type of program: / 4-yr degree / 2yr degree / Vocational/Technical

PAGE -3-

FINANCIAL INFORMATION PAGE(only if required)

1. Any scholarship that has a financial need as a requirement needs this page
2. Please include a copy of your parent/guardian 1040 for any scholarship that it is required for.
3. Please also attach the EFC “Estimated Family Contribution” Page from the FAFSA to the scholarships requesting it.

COST OF THE SCHOOL WHICH YOU PLAN TO ATTEND THIS FALL:

Tuition:
Room & Board:
Travel:
Miscellaneous:
Total Cost:

FAMILY RESOURCES AVAILABLE:

Ages of Children in the family; place a “C” next to each attending college next year (include yourself)

Ages of your parents (guardians): / Mother: / Father:
Father’s /Guardian’s occupation
Father’s /Guardian’s employer
Father’s /Guardian’s yearly income
Mother’s/Guardian’s occupation
Mother’s/Guardian’s employer
Mother’s/Guardian’s yearly income
Do guardians own their own home? / YesNo
If yes, what is its value today?
How much is still owed on it?
Student yearly income
Value of student’s savings, stocks investments, etc.
Other source of income (example alimony, child support, etc.)

INSTITUTIONAL RESOURCES: (put an X in the appropriate box)

Have you applied for Financial Aid? / YesNo
Form Used: FAFSA / YesNo / Profile: / YesNo
What Is The Expected Family Contribution (EFC) as it appears on your SAR?

What Financial Aid Package Have You Been Offered?

(If you have been offered no assistance, please note 0 below)

Grants (Scholarships, Awards)
Self-Help (work study)
Loans
TOTAL PACKAGE
Please feel free to note any additional pertinent comments on back put an X in box.

**If required, attach copy of your IRS page 1 to this page.

PAGE -4- ESSAY PAGE(only if required)

Include the necessary essay required for each scholarship. The essay must have the essay number and your social security number. Do not include your name. MAXIMUM length for any essay is one page typed single spaced.

E1.Write an essay describing why you have chosen your present major/career direction. Include any abilities, interests, experiences, employment, clubs, etc. you have had that have affected your direction. (If you are undecided, indicate why.) (For FCCLA Scholarship-indicate how FCCLA helped you in your High School career.)

E2. Write an essay describing how you feel you have personally contributed to Pomperaug High School.

E3. Write an essay in completion of this sentence: The continuation of my education will benefit mankind because…

E4. Discuss a person who, or an event that, has had a significant impact on you. Tell how it influenced your thinking and/or actions.

E5. Why is community service important? How has it personally affected you and your goals, and what role do you hope to play in it in the future? (For Middlebury Volunteer Fire Dept. Scholarshipplease list any community service you have personally accomplished).

E6. Discuss anything of importance to you that would help us to better understand you. This might include aspects of your abilities, interests, experiences, community service and aspirations.

E7. How has being a member of Panther Aquatic Club impacted your high school swimming career? If you are in college, how has it impacted your college swimming experience?

E8. If you had a child who demonstrated some aptitude for swimming as well as a love for it, would you encourage them to swim competitively and why?

E9. How has participation in sportsbeen beneficial to your personal, academic and emotional growth? Include the influence of the organization.(ForPomperaug Pop Warner Scholarship change sports to football or cheer. For PHS Softball Scholarships, change sports to Softball). (For Grid Iron Scholarship change sport to PHS Football).

E10. What does furthering your education mean to you?

E11. Why are youth sports an important part of the community?

E12. Write a one page essay expressing your involvement with UCC Southbury and how it has affected your life. Explain in what ways your UCC participation has been meaningful to you. (Please use the attached UCC Addendum)

E13. Why is sportsmanship an important part of sports? Provide examples of your own sportsmanship

qualities.

E14. Describe a challenge you faced and tell how you were able to address and overcome it.

E15. What soccer means to me? 250 word maximum (Please use the attached Southbury Soccer Addendum)

E16. How have you given generously of your time, treasure, and/or talents to improve the lives of others?

E17. How has the Southbury Public Library influenced you? **(Must include Library Card #)**

E18. Write a personal statement that demonstrates how you have given generously of your time, treasure, and or/talents to improve the lives of others.

E19. A Mason is taught to be of good character, to be a good citizen, to give back to the community and to help the less fortunate. What have you done during your high school career to emulate these characteristics?

PAGE -5- ESSAY PAGE (only if required)

E20. Describe the impact that PHS Field Hockey has had on you.(200 words max)

E21. How have veterans and/or the ideals of the Americanism they stand for influenced your life during your four years of high school? (200 words or less)

E22. This year there has been a focus on recognizing diversity and fostering attitudes of tolerance and acceptance. In relation to this ideal, tell us something about your experience at Pomperaug High School (in or out of school) that has challenged you to grow, and how this impacts you moving on after high school.

E23. Please write an essay on the following: The Knights of Columbus have dedicated themselves to the ideals of Charity, Unity, Fraternity and Patriotism. In 200 words or less, how have you exemplified one of these goals during your four years of high school?

E24. Please write a one page essay detailing your involvement with Middlebury Soccer and how it has affected your life. Explain in what ways your Middlebury Soccer participation has been meaningful to you.

E25. Please share with us something that you are passionate about, and how your experience during your time at PHS has contributed to that.

#1 Alfred Erk Scholarship

By signing below, the student affirms they have read and met the eligibility requirements on page one and that the application information is accurate and complete to the best of his/her knowledge, and that providing false or misleading information may result in revocation of any scholarship award. The applicant also affirms that neither they nor a member of their immediate family are employed by JPMorgan Chase Bank, N.A. or affiliates. Immediate family member is defined as spouse, domestic partner, child (natural, adopted or step), parent or step-parent, sibling (natural, half, adopted or step) father- or mother-in-law, grandparent, niece, nephew or spouse/domestic partner of a child, parent, sibling, grandparent, niece or nephew.

______

#43

ADDENDUM TO P.H.S. SCHOLARSHIP APPLICATION

UCC POPE EDUCATIONAL SCHOLARSHIP

UCC activities in which you have participated:

Activity9101112Special Involvement

______

______

______

______

______

E12. Write a one page essay expressing your involvement with UCC Southbury and how it has affected your life. Explain in what ways your UCC participation has been meaningful to you.

#122

ADDENDUM TO P.H.S. SCHOLARSHIP APPLICATION

SOUTHBURY SOCCER CLUB

Date: ______

Name: ______

Address: ______

Home Phone Number: ______

Education Information

______

Pomperaug High School

Graduation Date: ______

Grade Point Average (unweighted): ______

Signature of High School Official: ______

Title ______

College attending in the fall: ______

Soccer Information

______

Southbury Soccer Club

Number of years played for the Southbury Soccer Club: ______

What other soccer experience do you have? High School, Premier, District Team, Official Coach?

______

______

______

______