APPLICATION FOR THE

Andrew Gregory Rodgers and Pauline Rodgers

College Scholarship Program

2013-2014 School Year

STUDENT INFORMATION

Last name (use legal name), First, Middle Initial ______

Permanent address (number and street) ______

City/State/Zip ______County ______

Telephone Number ______Email ______

Class Rank (if graduating senior) _____ New application _____ or Renewal Application ______

Currently enrolled at (College/Univ. Name) __

Indicate enrollment status (PT=Part-time/FT= Full-Time) _____ College Major ______

Name of parent, guardian or spouse (if applicable) ______

Annual family income ______

Number of family members dependent on this income ______and enrolled full time in college ______

Are there any special circumstances that place a burden on your family (e.g., medical/dental expenses; children in college; death of a parent; unemployment, change in parental marital status). Please indicate and explain below.

By signing below, I certify that my accumulated GPA was 3.0 or higher as evidenced by the attached copy of my most recently received report card/transcript, and to the best of my knowledge the information contained in this application is true and accurate.

Student Signature Date


STUDENT ESSAY

Student Name (please print)

Please respond to the question:

How will college prepare you to live a life that contributes to Church and society?

Please list your participation in extracurricular activities and community service. Feel free to include any additional personal factors you would like us to consider in determining your scholarship eligibility, including demonstrated leadership or notable achievements.

Student Signature ______Date ______

Please attach your most recent report card/transcript.


LETTER OF RECOMMENDATION

Student Name (please print)

Please include WHY you are recommending this student and any comments you feel may be helpful in our application review process.

Recommender Signature ______

Date ______Relationship to applicant ______

Students, please send the completed application (pages 3, 4 and 5), along with your most recent report card/transcript to:

Andrew Gregory Rodgers and Pauline Rodgers

College Scholarship Program Fund

Catholic Community Foundation

1404 East 9th Street – 8th Floor

Cleveland, OH 44114