SECTION 1: PERSONAL INFORMATION

Last Name, First Name, MI /
Address
City, State, Zip Code
1. / Date of Birth
2. /
Male or Female
3. / Home Phone Number
4. / Cell Phone Number
5. /
Email Address
6. /
Are you a U. S. citizen/or legal permanent resident?
(Some scholarships require U.S. citizenship.) /
[ ] Yes [ ] No

SECTION 2: HIGH SCHOOLINFORMATION

7. / Current high school
8. /
High school principal name
9. / High school counselor name
10. / High school counselor’s email address
11. / Are you a high school senior? / [ ] Yes [ ] No
12. / Will you graduate in May 2013? / [ ] Yes [ ] No
13. / Cumulative GPA(Non Weighted)
14. / Class Rank
15. / ACT Composite Score
Last Name, First Name, MI /

16. ACADEMIC RECORD

List the names of the honors, advanced placement, and college classes, the letter grade, and academic year classes were completed.

NAME OF CLASS / GRADE / GRADE
Honors English I / A / 11th GR
a.
b.
c.
d.
e.

17. ACADEMIC HONORS

List the namesof top 5academic and leadership honors, name of institution awarding the honors, and academic year awarded.

NAME OF ACADEMIC & LEADERSHIP HONOR / INSTITUTION AWARDING HONOR / GRADE
Kansas Honors Society / University of Kansas / 11thGR
a.
b.
c.
d.
e.

18. EXTRACURICULAR ACTIVITIES HONORS

List the names of extracurricular activities, highest positions held and academic year of activities.

NAME OF EXTRACURRICULAR ACTIVITY / HIGHEST POSITION HELD / GRADE
Track / Captain / 12th GR
a.
b.
c.
d.
e.

19. COMMUNITY SERVICE

List the names of the organizations which you performed any community service activities, the names of the activity, and the academic year of the activities.

NAME OF ORGANIZATION / NAME OF ACTIVITY / GRADE
Salvation Army / Operation Holiday / 12th GR
a.
b.
c.
d.
e.
Last Name, First Name, MI /

SECTION 3: EDUCATIONAL INSTITUTION INFORMATION

20. /
Intended Major
21. /
List name of your #1 college/university you have applied and have been accepted to attend.

Many KHEDF scholarships are awarded based on the name of the college/university that you list above.
If you are awarded a scholarship from a college/university, the scholarship can only be used at that educational institution.

SECTION 4: FINANCIAL INFORMATION

22. /
Do you qualify for free or reduced lunch? / [ ] Yes [ ] No

A. EMPLOYMENT INFORMATION

23. / Are you employed? If yes, answer questions 24 and 25. /
[ ] Yes [ ] No
24. / How many hours per week do you work?
25. /
Name of current employer if employed
26. / Do you plan to be employed while you are attending college? /
[ ] Yes [ ] No

B. FINANCIAL ASSISTANCE INFORMATION

List all sources of financial assistance and scholarships you will receive for the 2013-2014 academic school year:

27 / NAME OF SCHOLARSHIP / TUITION, HOUSING, BOOKS, OTHER / AMOUNT / PER SEMESTER
Kansas State University / Books / $500 / $250/2 Semesters
a.
b.
c.
d.
e.
f.
g.
h.
28. /
Besides yourself, how many in your household will be attending college in the 2013-2014 academic years?
29. /
Are you the first person in your immediate family to attend a college or university?
/ [ ] Yes [ ] No
Last Name, First Name, MI

C: PARENT AND GUARDIAN INFORMATION

30. /
What is your family’sannualadjusted 2012gross income?
31. / Number of family members living in the household supported by the reported income listed above.
Household information—Indicate below who you live with.
(Check the appropriate column.)
Independent—live on my own
Live with both parents
Single parent household

SECTION 5: LETTERS OF RECOMMENDATIONS

The Kansas Hispanic Scholarship Program requires two letters of recommendation—Letters should be submitted from instructors and counselors in regards to your academic and leadership ability and/or employers and supervisors in regards to your community and work experience. Please mail letters of recommendations in the same large envelope with the other documents. Your school officials might prefer to send them in sealed letters which you can include in the large envelope.

SECTION 6: ESSAY

Each applicant must compose aone page double-spaced essay using 1” margins on the following topic:

“How do you see yourself becoming a positive role model in the Hispanic community?”

Please WRITE YOUR NAME, DATE, HIGH SCHOOL on the right hand corner of your essay.

SECTION 7: PHOTO

Each applicant is required to submit a photo of themselves along with their application. Please WRITE YOUR NAME AND HIGH SCHOOL on the back of your photo. High school graduation photos or professional photos are preferable as they will be used for the power point presentation at the awards ceremony or marketing of the scholarship program.

SECTION 8: TRANSCRIPT

An official transcript is required. Please contact the appropriate school administration office to obtain the transcript.

SECTION9: CHECK SHEET

Check off to show that you have each of the required documents below.
Then submit all the documents in a large manila folder to:

KHEDF

PO Box 4248
Wichita, KS 67204

Scholarships applications will not be processed if all documents listed below are not received by the deadline.

Scholarship Application / Pages 1-6
Essay / One page
2 Letters of Recommendation / Instructors, counselors or supervisors
Official Transcript
Photo / High school graduation or professional
Last Name, First Name, MI

SECTION10: PERSONAL STATEMENTS

Each scholarship applicantis REQUIRED to answer the following Personal Statements in the spaces provided.
Do not exceed one page.

a. / What are your academic and educational goals?
b. / Who or what, influenced your choice of your major?
c. / List awards or recognitions that youhave received which demonstrate your academic or leadership achievements?
d. / How have you been a positive role model in the Latino community?
e. / What school or community work are you most proud of?
f. / What financial obligations necessitate a need for a scholarship from the Kansas Hispanic Scholarship program?
g. / Are there any extenuating circumstances that you would like the committee to consider?
h. / What additional information would you like for us to know about yourself when considering you as a scholarship recipient?
Last Name, First Name, MI

SECTION 11: AWARD LETTERS

Award Letters will be mailed prior to May 1st. The Award Letters will include the amount of the scholarship, whether the scholarship is a one-time award or renewable, and the donor requirements. The name of the donor, company, and address will be included. If you are selected for a scholarship, a “Thank You” letter is REQUIRED.

SECTION 12: SCHOLARS ORIENTATION

Each year in late April, a Scholars Orientation will be held. If you are selected for a scholarship, attendance is REQUIRED.

SECTION 13: AWARDS BANQUET & SCHOLARSHIP RECOGNITION

Each year in late April or early May, a banquet & scholarship recognition will be held. If you are selected for a scholarship, attendance is REQUIRED.

SECTION 14: MAKING THE MOST OF COLLEGE WORKSHOP

Each year in late May or June a Making the Most of College Workshop will be held for all the scholarship recipients. If you are selected for a scholarship, attendance is REQUIRED.

SECTION15: CERTIFICATION AND AUTHORIZATION

All of the information that I have provided in this application and in the enclosed letters is accurate and complete to the best of my knowledge. I understand and acknowledge that providing false or misleading information may lead to the rescinding of my award.

I authorize the Kansas Hispanic Education & Development Foundation (KHEDF) to verify any of the information contained herein—either prior to, or after a scholarship is awarded.

I understand that if I am selected for a scholarship, attendance at the banquetscholarship recognition and leadership development workshop (unless excused for cause) is a condition of being awarded the scholarship.

I hereby authorize the Kansas Hispanic Education & Development Foundationto use any information contained in this application for the purpose of promotion of the Kansas Hispanic Scholarship Program.

Applicant signature Date

Parent or

Guardian’s signature Date

(Parent or Guardian’s signature is required if applicant is under 18 years of age.)

SECTION 16: RELEASE OF RECORDS

I hereby authorizepermission to release my secondary school records and other requested information for consideration in the Kansas Hispanic Scholarship Program.

Applicant signature Date

Parent or

Guardian’s signatureDate

(Parent or Guardian’s signature is required if applicant is under 18 years of age.)

SECTION 17: MAIL APPLICATION AND DOCUMENTS TO:

Kansas Hispanic Education & Development Foundation

PO BOX 4248
Wichita, KS 67204

Applications must be postmarked by Friday, February 1, 2013.

If you have any questions, please email Irma Luna at .

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