Dubois County Common Scholarship Application

DUBOIS COUNTY COMMON SCHOLARSHIP APPLICATION

FOREST PARK HIGH SCHOOL

Scholarship for which you are applying ______

SECTION A

Name:______

LastFirstMiddle

PERSONAL INFORMATION:

Social Security Number:______Age: ______

Resides in

Household Deceased

Father/Guardian’s Name ______( )( )

Mother/Guardian’s Name ______( )( )

Stepfather’s Name ______( )( )

Stepmother’s Name ______( )( )

Home Address: ______

Street AddressCity State Zip

ACADEMIC INFORMATION:

Grade Point Average______Class Rank ______out of ______

Highest SAT Critical Reasoning ______Highest SAT Math______Highest SAT Writing ______

Composite ACT Score______

College You Plan to Attend ______

Intended College Major______Years Required to Complete This Degree____

Have you received an official letter of acceptance at this time? Yes_____No_____

HOUSEHOLD INFORMATION:

Father’s Occupation: ______Employer: ______

Mother’s Occupation: ______Employer: ______

Number of brothers and sisters residing in household:Older______Younger ______

Please list any brothers and sisters in a post high-school educational program and list the name of

the institution. ______

Do you have any extraordinary family expenses? Please explain. ______

______

SECTION B

1) Federal Adjusted Gross Income (per Federal Form 1040 for the household)

$0 to $20,000 ______

$20,001 to $30,000 ______

$30,001 to $40,000 ______

$40,001 to $60,000 ______

$60,001 to $80,000 ______

Over $80,000 ______

Exemptions claimed by household on Federal Form 1040______

Other Aid/Income (circle appropriate item :)

Tips, Welfare benefits, Social Security, Non-taxable pensions, Child Support,

Workers Compensation, Other (List): ______$

Child support paid out by household $

2) Applicant’s estimated resources for the next academic year.

a)Resources:

Projected Summer Income $ ______Total Personal Savings $______

Projected earnings during the next school year $ ______

b)Please list all scholarships and amounts that you have already received as of April 1.

Scholarship: ______Amount: $ ______

c) Are you presently employed? ______Employer ______

Describe your other work activities (such as family farm, helping at home, etc.)

______

SECTION C

1)Applicant’s estimated expenses for the next academic year.

a)Expenses

Tuition & Fees$ ______

Room and Board $ ______

b) Other Specialized Fees$ ______Explain ______

I HEREBY TESTIFY THAT THE ABOVE INFORMATION IN SECTION B AND C IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

______

Applicant’s signature Parent or Guardian signature

SECTION D

Individual Student Profile

Name or type of Diploma to be received: ______

High School activities in which you have participated: (clubs, extracurricular, sports, etc.)

Years Years

a)______g)______

b)______h)______

c)______i)______

d)______j)______

e)______k)______

f)______l)______

Awards, Honors, or Letters you have received:

a)______e)______

b)______f)______

c)______g)______

d)______h)______

Leadership positions held: (Includes academic, athletic, community, and/or workplace.)

a)______e)______

b)______f)______

c)______g)______

d)______h)______

Services you have rendered to your school and/or community:

a)______c)______

b)______d)______

Community organizations to which you belong:

a)______b)______

Community Leadership roles: ______

Community honors received: ______

Exceptional or original talents you feel you have demonstrated in the areas of art, music, science,

literature, mathematics, or industrial arts:

______

Principal strengths as a person: ______

Principal academic strengths: ______

ATTACHMENTS

A copy of your transcript showing information for three and one-half years of high school.

A reference letter from a teacher or administrator supporting your academic and personal record. This can be a copy.

A statement of 200 words or less as to why you are preparing for your vocation and why you are applying for this scholarship.