SCHOLARSHIP APPLICATION (RENEWAL)

Transcription

1 PURPOSE To provide supplemental financial assistance to those single parents who are pursuing a course of instruction which will improve their income earning potential. ELIGIBILITY CRITERIA If you have continuously received this scholarship each Spring and Fall since Spring 2017, continue to follow the guidelines under which you entered our program. REQUIREMENTS: The following documents need to be submitted on or before the application deadline: 1. Proof of enrollment - Class schedule for upcoming term or registrar verification. If a class schedule is not available at the time of your application, you may submit verification from the registrar with your application. However, a class schedule must still be provided before your scholarship is awarded. 2. Proof of income - Tax return (first page of most recent year). If you are exempt from filing a tax return, submit a Proof of Income statement from the Department of Human Services. Other income verification may be considered if these documents do not apply to your situation. 3. Pell Grant (FAFSA) copy of your Student Aid Report (SAR), or letter from your school s Financial Aid Office that states your approval or denial for financial aid during the term for which this scholarship is to be used. If you did not apply for FAFSA, provide an explanation. 4. Current transcript - An unofficial copy of your transcript showing your most recent grades, with cumulative GPA. You may download or print this from your school's website. 5. Statement of goals- Must be a one-page personal essay that describes your career objectives and financial need. DEADLINES: Fall Semester: June 15 (Priority Consideration), July 15, September 15 Spring Semester: December 15 Summer Semester: May 15 You may receive up to three (3) scholarships per year. You must reapply each semester that you need a scholarship. QUESTIONS: Cherie Conner Phone: cconner@northark.edu Updated Page 1 of 6

2 Deadlines: Fall June 15, July 15, September 15 Spring December 15 Summer May 15 PERSONAL INFORMATION 1. Name 2. Gender: Male Female Last First Middle Maiden 3. Address Street or PO Box City State Zip 4. Phone: (Home) (Cell) 5. ( ) 6. Social Security Number: 7. Birthdate: 8. Marital Status: Never married / single Widowed Divorced Legally separated* Married but living apart* 9. How long have you been a Boone County resident? Years Months 10. Including you, how many individuals are dependent on you for financial help or support? 11. Tell us about your children: Name of Child Age Date of Birth Type of Medical Insurance 12. Race: for reporting purposes only has no effect on your eligibility for this scholarship Black Asian Hispanic Native American Caucasian Other HOUSEHOLD INFORMATION 13. Is anyone sharing your household expenses? (excluding expenses paid by government assistance) YES NO 14. Do you have any relatives living in the area? YES NO 15. What assistance do your relatives provide to you and your children (check all that apply)? Housing Financial Help Transportation Childcare Other None Updated Page 2 of 6

3 16. Do you have medical insurance? YES NO 17. Do you own a personal computer? YES NO SCHOLARSHIP APPLICATION EDUCATIONAL INFORMATION 18. What college or university will you be attending? 19. Major: 20. Number of hours enrolled: 21. Anticipated graduation date (month and year): 22. List below the schools you have previously attended (Example: West Side High School; ) Grade school: High school or GED: Trade or Vocational: College or University: Military: Other: School Name Dates Attended FINANCIAL AID INFORMATION 23. Have you applied for federal financial aid (FAFSA)? YES NO 24. Have you been awarded federal financial aid (FAFSA)? YES NO 25. Complete the following for the academic year for which you are applying for this scholarship: Semester Pell () Student Loans () SEOG Grant () Work Study () Other Financial Aid () Fall 20 Spring 20 Summer For what types of costs do you plan to use the Single Parent Scholarship? Updated Page 3 of 6

4 27. Have you ever applied for a Single Parent Scholarship? YES NO FINANCIAL INFORMATION 28. List all sources of income you are currently receiving (Column A) and expect to receive in the next twelve months (Column B) Column A - Income received LAST 12 MONTHS Column B Income expected NEXT 12 MONTHS Monthly Annual Monthly Annual Friends/Family Employment Reserve Armed Forces Unemployment Benefits Social Security Rehabilitation HUD Rental Assistance TEA Child Support Food Stamps (SNAP) VA Benefits Other Income (List Below): TOTAL INCOME Updated Page 4 of 6

5 29. What are your average out of pocket monthly expenses? (List dollar amounts below) Monthly Housing Utilities (electric, gas, phone, water) Food Transportation & Car Maintenance Insurance Coverage Loan Payments Clothing Medical Costs (checkups, etc.) Child Care Household Goods Other Expenses (please list) TOTAL EXPENSE EMPLOYMENT INFORMATION 30. Will you be working while you attend school? YES NO If YES, how many hours per week will you work? 31. List your employers for the past 5 years, beginning with the most recent. If you have not been employed outside of the home, list your major home and community activities for the past five years. Name Address Job Title Dates From-To Updated Page 5 of 6

6 RELEASE OF INFORMATION The following is OPTIONAL but your assistance in these areas is greatly appreciated: I hereby give permission to Arkansas Single Parent Scholarship Fund to use information about my background, experiences and academic accomplishments in promotional materials. Yes, with my name Yes, but anonymously No If asked, I am willing to speak at civic clubs, churches, or other engagements in which members of the community want to learn about the activities of the Arkansas Single Parent Scholarship Fund. Yes No I hereby give permission for all financial and academic information related to this application including financial aid, number of hours of enrollment, and grades to be released, upon request, to the Arkansas Single Parent Scholarship Fund. I also agree to participate in follow up research conducted by SPSF/Boone County after I am no longer receiving scholarship awards and hereby give permission to SPSF/Boone County to obtain enrollment and graduation information from my school as is needed for their subsequent reports. Signature Date CERTIFICATION Check each blank below to insure you have included all required documents with your application Completed application form (pg 3-6) Proof of Enrollment Proof of Income Pell Grant (FAFSA) Student Aid Report or Award Letter Current Transcripts Statement of your goals Signed Release of Information (pg 7) Signature Date Return your completed application form, reference letters, personal statement and transcript(s) to: Single Parent Scholarship Committee ATTN: Cherie Conner North Arkansas College 1515 Pioneer Drive Harrison, AR Updated Page 6 of 6