PARENTAL DATA
Father’s Full Name ______________________________________________________
Home Address _______________________________Telephone (____) ___________
Occupation ______________________ Employer ____________________________
Business Address________________________________________________________
Years in Present Position ________
Mother’s Full Name______________________________________________________
Home Address _______________________________Telephone (____) ___________
Occupation ______________________ Employer ____________________________
Business Address________________________________________________________
Years in Present Position ________
Marital Status: Married - ______ Separated - ______ Divorced - ______
Parent(s) Deceased- Mother ____ Date-__/__/__ Father ____ Date __/__/__
DEPENDENT DATA
Siblings: Name Age School / College Attending
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Additional Dependents: Name Age Relationship
________________________________________________________________________
REFERENCE DATA
Please indicate the names, addresses, phone numbers and preferred time of day to contact your references. It is your responsibility to notify your references that the Scholarship Committee will contact them for a reference.
Name Address Phone Best Time(am/pm)
BUSINESS REFERENCE (An employer for whom you have worked)
________________________________________________________________________
PERSONAL REFERENCE (An adult who knows you well)
_____________________________________________________________________________________
CHURCH, TEMPLE, OR COMMUNITY SERVICE REFERENCE (Optional)
ACTIVITY AND ACHIEVEMENT DATA
Academic Honors: Please list scholastic distinctions
or honors you have won since starting Grade 9.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
School Activities: Please list your principal
activities within the school community. Give grade levels or years of
participation, the approximate number of hours spent per week, and positions
held or honors won.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Outside Activities: Please list your principal
activities not connected with school, include hobbies, community, church
or temple, and family activities. Give grade levels or years of participation,
the approximate number of hours spent per week, and positions held or honors
won.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Work Experiences: Please list any jobs you have
held during the past three years (include summer employment). Specify the
nature of the work, employer, dates of employment and hours per
week.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Summer Plans: Please indicate your plans for the
up-coming summer, include earning expectations.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Applications: In order of preference, please list all colleges to which you have applied. Please state your intended major and the degree you will seek.
Major: _____________________________________Degree: ________
College Why Chosen Cost/Year
1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
5.______________________________________________________________________
6.______________________________________________________________________7.______________________________________________________________________8.______________________________________________________________________
Scholarships: Please list all scholarships for which you have applied.
Name of Scholarship/Amount
1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
Financial Disclosure: Please indicate sources and amounts of money you expect to have available for college each year:
Your contribution-$___________ Parents-$____________ Other-$ ____________
Please indicate parents’ combined earned income before taxes:
Under $20,000 _____ $20,000-$30,000 _____ $30,000-$40,000 _____
$40,000-$50,000 ______
$50,000-$60,000 _____ $60,000-$75,000 _____ $75,000-$100,000 _____
Over $100,000 ______
Other Income: $ ____________________
Extraordinary Expenses: (Please explain) ________________________________________________________________________________________________________________________________________________
________________________________________________________________________
ESSAY
On a separate sheet of paper which is to be attached to this application, please write a 250-word essay on one of the following topics. Your essay will be evaluated on its relevance to the chosen topic, lucidity of expression, creativity, and correctness of grammar, and spelling. In addition, your essay will be used as a tool for us to learn more about you.
Respond to one of the following topics:
Discuss your career goals.
Describe a challenging or enriching experience you have had and your response to it.
Why do you value an education?
What factors are most important for a successful life?
What is the responsibility of all individuals to others and to the world?
APPLICANT UNDERTAKING
I understand that to receive scholarship funds I must be a candidate for a baccalaureate degree. Further, I must maintain good academic standing. My academic progress will be substantiated by submitting a complete college transcript to be sent by the college registrar to the College Woman’s Club of Westfield no later that July 1st of each academic year.
If the award recipient does not conform to the policy of the College Woman’s Club, it will be assumed that the recipient is no longer interested in receiving the scholarship, and the payment of funds will be terminated.
All winners are strongly encourage to write to the Scholarship Committee at least once a semester regarding their college plans and progress.
Additionally, by signing this application, I am releasing to the scholarship committee a copy of my high school transcript including grade point average, class rank, and SAT scores.
I attest that, to the best of my knowledge, all information furnished in this application is true and complete.
Signature of Applicant
Date
Signature of Parent or Guardian
Date