BOYS & GIRLS CLUB HIGHER EDUCATION SCHOLARSHIP 2018 Scholarship Application (608)

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1 Available Scholarships Brian & Paula Soller Leadership Scholarship David Pierce Memorial Scholarship George Nixon/UWL Scholarship Jim Loken Memorial/Alumni Association Scholarship Art Peterson Memorial Scholarship Terry & Sue Erickson Family Scholarship Lommen Family/McDonalds Youth Achievement Scholarship Don Kish Memorial Scholarship Michelle LaRoche Memorial Scholarship Scholarship Criteria The recipient should demonstrate a financial need for this scholarship with the intent of helping a boy or girls attend a college, university or technical school, who might not otherwise be able to do so. The recipient must have a current or past affiliation with the Boys & Girls Clubs. The recipient must have an above average grade point and demonstrate the ability to succeed in higher education. The recipient should have demonstrated leadership qualities, both as a Boys & Girls Club member and as a high school student. The recipient should have made notable contributions to school, family and the community. Application Submission COMPLETED APPLICATIONS MUST BE RECEIVED BY FRIDAY MARCH 30 th 2018 Scholarships recipients will attend the BGC Celebration of Champions on Wednesday May 9 th Please return completed form to: Boys & Girls Clubs of Greater La Crosse Attn: Scholarship Committee PO Box 91 La Crosse, WI Completed scholarship applications may also be submitted via to: Abby.Stauder@bgclax.org Application Submission Certification I certify that all the statements made in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. Applicant Signature: Date:

2 Applicants Information Full Name of Applicant: Address: City: State: Zip: Phone: Age: Sex: Father/Guardian Name: Father/Guardian Occupation: Mother/Guardian Name: Mother/Guardian Occupation: College Application Data Please Indicate the schools you have applied to (in order of preference) School #1: State: Accepted by School:(circle) YES NO Attending:(circle) YES NO School #2: State: Accepted by School:(circle) YES NO Attending:(circle) YES NO What is your intended Major of study: What is your intended Minor of study: Academic Information High School you currently attend: Rank in High School Graduation Class: out of (Total # of Students in Class) High School Grade Point Average(GPA): ACT Composite Score: SAT Composite Score: Verbal: Math: List other certifications or Academic Achievements:

3 Financial Information Some scholarships are based on financial need. The information you provide will be kept confidential. If you would like to be considered for one of these scholarships, please complete this section. Your response will help the committee evaluate the composition of the applicant population. Financial Data What were your parents approximate combined income before taxes last year? Include taxable and non-taxable income from all sources: (circle one) Less than $10,000 $40,000 to $50,000 $80,000 to $90,000 $10,000 to $20,000 $50,000 to $60,000 $90,000 to $100,000 $20,000 to $30,000 $60,000 to $70,000 More than $100,000 $30,000 to $40,000 $70,000 to $80,000 Total number in Household: (include parents/guardians or spouse, brothers/sisters or children, and yourself) Total number of college students in Household for the school year: (at least half-time during one or both terms) School, Community, & Employment Information School Data List your school activities, sports, & offices held. Indicate (circle) the years in school you participated in these activities. Include activities you will be involved in during semester 2: Community Data List your community activities and offices/employment held. Indicate (circle) the years in school you participated in these activities. Include activities you will be involved in during semester 2: School & Community Awards/Honors/Achievements Data List your community and school awards/honors/achievements. Indicate (circle) the years in school you participated in these activities. Include activities you will be involved in during semester 2:

4 Boys & Girls Clubs Involvement Please give a short history of your involvement as a member of the BGC Leadership Potential Several of our scholarships are based on leadership qualities Please specify any offices held or leadership roles you have taken on that should be considered by the committee. Limit your response to this field.

5 Post-Secondary Statement Please state why you intend to enter post-secondary education and what you hope to accomplish. Limit your response to this field. Special Needs Please specify any needs, hardships or extenuating circumstances you would like to have considered by the committee. Limit your response to this field.