2015 Application for Lomira Local Scholarships
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1 2015 Application for Lomira Local Scholarships Below is a list of local scholarships available for Lomira High School students. By completing this one form, you will be considered for all those for which you qualify. The full description of each scholarship is available in the counseling office. Both the application form and the reference form are available under the Scholarship link on the home page. Erik Baxter Memorial Scholarship Be the Change Lomira and Brownsville Lions Service Scholarships Bintzler-Waehler American Legion Scholarship Bintzler-Waehler American Legion Auxiliary Scholarship K.M. Kitty Braun Memorial Scholarship Jerry Burmeister Memorial Scholarship Alfons Dehring Memorial Scholarship Kondex Corporation Scholarship Dr. G.P. Langenfeld Memorial Scholarship Lomira Area Chamber of Commerce Scholarship/Future Business Leaders of America Lomira Area Chamber of Commerce Scholarship/Future Farmers of America Lomira Education Association Scholarship Lomira Senior Foundation Scholarship Lomira Alumni Foundation Scholarship Lomira H.S. Sports Booster Club Scholarship Lomira Parents and Teachers for Children Scholarship Dale Michels Family Endowed Scholarship Earl Qualman Memorial Scholarship Theresa Lions Club Scholarship Theresa Parent Teacher Club Scholarship Theresa Parent Teacher Club Delores Justman Theresa Elementary School Scholarship You will be considered on the basis of this application, your references and your transcripts. Please prepare the application carefully by typing or printing clearly in black or blue ink. Answer each question as completely as you can, not exceeding 150 words. Please be thoughtful and concise. This application, including your references (two school-related and one non-school-related), and transcripts from Lomira High School (request from Mrs. Halverson or Mrs. King in the HS office) must be submitted to the guidance office no later than 3:30 pm on Friday, March 20, Incomplete applications or those received after March 20, 2015 will not be considered. You must also complete the online version of the application and upload a copy of your essay. Page 1
2 GUIDANCE USE ONLY Date this application is submitted 1. Personal Data GUIDANCE USE ONLY Class Rank: GPA: HS Transcripts: HS References: Non-school School School A. Name: B. Street Address: C. City, State ZIP: D. Phone: E. F. Father/Guardian Name: G. Address: H. Phone: I. Mother/Guardian Name: J. Address: K. Phone: L. Father's Occupation: M. Employer: N. Mother's Occupation: O. Employer: Names & ages of other dependents in household P. (Be sure to include other children in college): The following questions relate to the criteria of specific scholarships (please select only one answer for each question): Are you a citizen of the United States? Yes No What is your gender? Male Female What is your heritage? African/American Caucasian Hispanic Other Were you raised on an operating farm? Yes No Do you have a disability as defined by the WI Dept of Public Instruction? Have you participated in the special education program? Yes No Will you be a full or part time student at the postsecondary level in ? Full-time Part-time Are you or have you been a member of FBLA? Yes No Are you or have you participated in a bowling league? Yes No Are you a member of National Honor Society? Yes No Page 2 Yes No
3 Are you a member of FFA? Yes No Are either of your parent/guardian a member of the Yes No American Legion or Legion Auxiliary? Are any of your grandparents a member of the American Yes No Legion or Legion Auxiliary? Did you attend Theresa Elementary School? Yes No Did you attend Lomira Elementary School? Yes No Did you attend Lomira Middle School? Yes No Are you a child of a Theresa Lions Club member? Yes No Are you the child or grandchild of a veteran? Yes No What was your highest composite ACT score? 2. Education Transcripts of all high school courses are required. Be certain to request these items early because applications submitted without transcripts will not be considered. Schools attended if other than Lomira High School: Dates: 3. List school/academic awards received. 4. Please complete the following chart in regards to the sports activities you have participated in. List only the sports in which you COMPLETED the entire season. Year and Level Sport Lettered? Regional, Sectional, (i.e.freshmen=f, Varsity=V) Awards (If so, please list years) example:9f, 10 JV/V, etc. or State Competition 5. List major hobbies. 6. List major extra-curricular activities in and out of school, including length of participation and offices held. 7. Describe your work history beginning with most recent first. Employer Job Hours Per Week Period Worked 8. Describe your volunteer history during the last four years. Organization Activity Hours Per Week Period Worked Page 3
4 9. Please write a statement on the value of service and how it has impacted you personally. 10. Please explain how you have been able to give back to the Lomira Elementary and/or Middle School students. 11. What is your intended major and/or career? Why? 12. Where do you plan to go to college? Why? 13. What has your participation in extra-curriculars taught you that you can use in the future? 14. If you have participated in sports, please comment on why you are deserving of a Lomira Sports Booster Club scholarship and how the Booster Club have acted as a support system to the athletic program and your athletic career at LHS? 15. How do you plan to finance your education? 16. What do you anticipate will be your schooling costs for the coming year? Tuition Room & Board Books & Fees Total: 17. What is the basis for your estimate? Give the name and date of the college catalog or other source. 18. Have you been notified that you are to be awarded any other scholarships or grants? If so, please give name, date, and amount. 19. ESSAY: Please explain how your education at Lomira High School has taught you the importance of responsibility. Page 4
5 20. Please list the names, signatures, business telephone numbers, and s of the three adults whom you are asking to complete reference forms for you. They must not be related to you and they must know you currently. Two must be school-related (at least one teacher). The third must be a non-school-related person (i.e., employer, minister). As a courtesy to your references, you are to provide each reference a copy of the form with an addressed, stamped (if necessary), standard business envelope. References can also fill out the form on-line ( click on the scholarship link). Please remind your references by word or telephone a few days before the application date. A missing reference could mean denial of a scholarship. Non-school-related School-related School-related Name Signature (if using online reference form) Business Phone AND Address High school transcripts are required. If they are not included with your application, the application will not be considered. Requesting transcripts from the HS office is your responsibility and not that of the Guidance Department. I certify that the information contained in this application is correct. I further certify that I will attend LHS AWARDS NIGHT if I am notified that I have received a scholarship. FAILURE TO DO SO MAY RESULT IN THE FORFEITURE OF MY SCHOLARSHIP. I also agree that, if I am awarded a scholarship and decide not to go on to school, I will notify the LHS guidance department in writing by AUGUST 1, 2015 at 1030 Fourth Street, Lomira, WI This will allow an alternate to be selected for a scholarship. Student Signature: Date: I am aware that if my son/daughter does not turn in this application before the deadline (Friday, March 20th, 2015 before 3:30 pm to the HS Guidance Department), the application will not be considered. I am also aware that my son/daughter has an obligation to attend LHS AWARDS NIGHT if they are informed that they are receiving a scholarship or they risk forfeiture of the scholarship. Parent Signature: Date: Please submit this form to the LHS Guidance Office at 1030 Fourth Street, Lomira, WI postmarked by no later than March 20, Page 5
6 Lomira Local Scholarship Reference Form Name of Applicant: The above named student has given your name to us as a reference for help in evaluating a scholarship application. Any insight based on your experience that would aid us in our consideration and help us to distinguish this applicant from others would be appreciated. Please be specific and frank as possible, yet concise. You need NOT list the applicant's activities, grades or future plans. Those are reported in the application form. All information will be held in strictest confidence. Scholarship Leadership Adaptability Initiative Reliability Integrity Self-discipline Below Average Average Above Average Excellent Outstanding How do you know the applicant? If teacher or coach, give the subject; if employer, the company. Please include length of time you have known the applicant and any additional comments. Signature: Date Type Name: Place of Employment and Position Held: Business Telephone Number: Page 6
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Joint Civic Committee of Italian Americans Women s Division 3800 Division Street, Stone Park, Illinois 60165 (708) 450-9050 - Fax (708) 450-9065 E-Mail Address JCC@JCCIA.com or visit our web site at www.jccia.com
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