The Charity League of Martinsville and Henry County
c/o Carrie Metzger
407 Rives Rd.; Martinsville, VA 24112

2017 Application for Scholarship to be completed by the Student and returned to Guidance Counselor byApril 1, 2017.

  1. Full Name of Student: ______
  2. Address: ______
    ______

Phone Number: ______
Email: ______

  1. Date of Birth: ______
  2. Present High School Attending: ______
    ***Please attach a copy of your complete transcript, including SAT scores.
  3. Total Family Income (Gross): ______
    Father’s Name: ______
    Place of Employment: ______
    Mother’s Name: ______
    Place of Employment: ______
    ***Please submit photocopies of your parents’ or guardians’ W2 and 1099 forms for 2016.
  4. List any siblings living at home or away that are supported by your parents or guardians. Also list sibling’s name, age, school now attending, or occupation.
    ______
  5. List any relative or other persons that provides financial assistance to you and the amount: ______
  6. Have you applied for or been approved to receive:

Pell Grant: ______Amount: ______
Any other Grant: ______Amount: ______
Financial Aid: ______Amount: ______

College Work Study Program: _____Amount: ______

Other: ______Amount: ______

If you have not applied for other financial assistance, explain why you have not applied: ______

Have you or your parents/guardians established a 529 college savings plan? If so, what is the value of this account: ______

  1. College or Vocational School you plan to attend: ______

Have you been accepted for admission at the above college/school? ______

  1. Academic Objective (course of study you plan to pursue upon graduation from high school): ______
  2. Vocational Objectives (future job or occupation you plan to pursue): ______
  3. List church, youth and volunteer activities: ______
  4. Hobbies and Special Interests: ______
  5. Present and Past Work Experience: ______
  6. Present and Past Honors or Awards: ______
  7. Present and Past School Activities: ______
  8. Tell us about any personal skills, characteristics or special aptitudes that you have: ______
  9. Do you have any disabilities or illness? If, so please explain: ______
  10. Write a brief summary about how a scholarship award could positively impact your future educational goals. Use the space provided below. Use extra sheet if necessary.
    ______

Please return completed application and all attachments to your Guidance Counselor by April 1, 2017.

The Charity League of Martinsville and Henry County
c/o Carrie Metzger
407 Rives Rd.

Martinsville, VA 24112

2017Confidential Information on Student
To be completed by student’s guidance counselor.
Please return with student’s application by April 1st, 2017.

  1. Full Name of Student: ______
  2. Parents or Guardians:
    Father’s Name: ______
    Mother’s Name: ______
  3. Any background information on family or guardian that might help us in our decision: ______
    ______
  4. Special personal characteristics, skills and aptitudes of students: ______
    ______
  5. What is student’s motivation, maturity, character, and ability to set and pursue realistic goals? Overall potential as a college or vocational student? ______

Name of person completing this form: ______
Position/Title: ______
Signature: ______

Return completed form, SAT scores and official transcript to:

Mrs. Carrie Metzger

407 Rives Rd.

Martinsville, VA 24112

The Charity League of Martinsville and Henry County
c/o Carrie Metzger

407 Rives Rd.; Martinsville, VA 24112

Scholarship Information Checklist

Please make sure the following items are included in your packet.

  1. Completed Application Form______
  2. Official Transcripts______
  3. SAT Scores______
  4. Copies of parents’ or guardians’ W2 and 1099 forms for 2016 ______
  5. Confidential Information Sheet_____