MAQUOKETA VALLEY DOLLARS FOR SCHOLARS APPLICATION
To The Applicant:
This application is designed to determine your eligibility for receiving funds set aside to aid students who are preparing to pursue a post secondary education and who can satisfy other criteria developed by Scholarship America.
Complete your sections of this application and deliver them to the high school career/college center. You also need to contact a reference to complete the appraisal (attached). This reference may be a teacher, work supervisor, member of the clergy or a non-family member who is in a position to evaluate you according to the criteria given. You may wish to provide the appraiser with information related to your academic and extra-curricular achievements and community involvement. Provide this reference with an addressed envelope to return the appraisal to the high school career/college center. At that point, the transcript information section will be completed.
If any questions are not applicable to your current situation, please include an explanatory note referring to the questions. Also, if you require more room for a response to a question, please attach additional information or use the back of the application form.
It is your responsibility to submit all of the required information. Scholarship America and its affiliate programs reserve the right to process only applications found to be complete.
The following information is required for a complete application:
ü application
ü appraisal form (given to ___________________________________________)
All of the information must be received by the high school career/college center by 3:30 pm on March 15, 2010.
Certification
In submitting this application, I certify that the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in termination of any scholarship awarded.
Applicant’s Signature ___________________________________________Date____________
Applicant’s Name ___________________________________ I.D. # __________
Maquoketa Valley Chapter Dollars for Scholars
2010 AWARDS ELIGIBILITY
The M V Chapter of Dollars for Scholars hopes to distribute a scholarship for every applicant this year. The dollar amount of these awards will start at $250.00. Most awards are open to any student who applies, but a few have restrictions named by the donor with the approval of the MV Dollars for Scholars Board. If you are qualified, your name will then be placed on a list to be considered for these restricted awards.
a Please review the list below and check any items that describe you. Provide the details of your activities on your application form if you check any items below.
___ My home is in or closest to the Delhi elementary school area.
___ My home is in or closest to the Earlville elementary school area.
___ My home is in or closest to the Hopkinton elementary school area.
___ I am planning to attend Kirkwood Community College in Cedar Rapids.
___ I am planning to study technical or trade skills at a 2-year school.
___ I have been active in fine arts, speech, drama, or music. Circle all that apply.
___ I plan to be a teacher or work in the field of education.
___ I will enter the health care field (nursing, doctor, dentist, medical. technology, etc.)
___ I will study in the field of agriculture.
___ I have shown leadership in community activities and in my church.
___ I take an active role in my church through regular attendance, youth activities, and service.
___ I have been active in athletics (at least 3 years in 2 or 3 sports).
This list, along with your other application materials, is due at the M.V. Career College Center by 3:30 p.m. on March 16th, 2009.
IMPORTANT DATE TO SAVE
May 10, 2010, 7:00 p.m., MAQUOKETA VALLEY SENIOR AWARDS NIGHT
I.D. # _____________
Please Print or Type
APPLICANT DATA:
_____ ___ _________ _____________
Name (last) (first) (middle initial) Social Security #
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Permanent Address (street) (city) (state) (zip)
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Date of Birth (month/day/year) Telephone Number
Name of Parent/Guardian: _ ______ _
Permanent mailing address of Parent/
Guardian if different from applicant: _ ______
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Telephone Number
SCHOOL DATA:
Name and Address of post secondary school for which Scholarship is requested:
_ ___ _
Anticipated date of graduation from post secondary program (month/year):__ ________
Major field of study applicant plans to pursue: _ __________
WORK EXPERIENCE:
Describe your work experience during the past four years. Indicate dates of employment in each job and approximate number of hours worked each week. List total amounts earned at each job.
Position Employer Dates Worked Hours / week Amount Earned
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I.D. # ___________________
PERSONAL DATA:
List all school activities in which you have participated during the past 4 years (e.g., student government, music, sports, etc.) List all community activities in which you have participated without pay during the past 4 years (e.g., Red Cross, church work, volunteer work). Indicate all special awards and honors.
Activity Years Participated Special Awards, Honors, Offices Held
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_ ____________________________________
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Make a statement of your plans as they relate to your educational and career objectives and future goals.
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Please describe how and when any unusual family or personal circumstances have affected your achievements in school, work experience, or your participation in school and community activities.
__ ________________
_ ____________________________________
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I.D. # _____________
FINANCIAL INFORMATION:
Applicant: Please fill out this page with the help of your parents.
Rate your family’s (parents, grandparents, others) ability to help finance your post secondary education. If their ability to help you pay is low, circle a lower number and explain. If they can help quite a bit, circle a higher number.
1 2 3 4 5 6 7 8 9
Low High
Please explain how you arrived at this rating:
What percentage of your continuing education will you finance yourself through working, student loans, scholarships, or other sources of money:
_____ _ % (If you must pay for all of your education, the number will be 100%; if you have some
financial help from parents, the number will be less.)
Please explain:
APPLICANT’S NAME: ________________________________________ I.D. # ___________________
APPLICANT APPRAISAL FORM: To be completed by a teacher, work supervisor, member of the clergy or a non-family member who is in a position to evaluate the applicant according to the criteria given.
Appraiser: You have been asked to provide information in support of this application for a scholarship. Please respond to these statements by circling the most accurate response. When complete, please return to the high school Career/College Center (Maquoketa Valley High School, P.O. Box 186, Delhi, IA 52223) in a sealed envelope by March 16.
1. The applicant’s choice of a postsecondary education program is
extremely appropriate very appropriate moderately appropriate not appropriate
2. The applicant’s achievements reflect his/her ability
extremely well very well moderately well not well
3. The applicant’s ability to set realistic and attainable goals is
excellent good fair poor
4. The quality of the applicant’s commitment to school and community is
excellent good fair poor
5. The applicant is able to seek, find and use learning resources
extremely well very well moderately well not well
6. The applicant demonstrates curiosity and initiative
extremely well very well moderately well not well
7. The applicant demonstrates good problem solving skills, follows through and completes tasks
extremely well very well moderately well not well
8. The applicant demonstrates respect, honesty, sincerity and responsibility
extremely well very well moderately well not well
Comments (Please do not make any reference to the student’s name in your description.)
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Appraiser’s Signature Relationship to Applicant Telephone number
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Appraiser’s Address (street) (city) (state) (zip)
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TRANSCRIPT INFORMATION: This section must be included and filled out by an appropriate school official.
Applicant ranks ______in a class of ______. Cumulative grade point average:_______/4.0 scale
PSAT Verbal _______ Math _______ ACT Standard English _______ Math
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School Official’s Signature Date Title