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Name:
_______________________________
Date:
____ / _____ / _____
Address:
_______________________________
Phone:
( ) _____-______
_______________________________
Overall G.P.A.
_______________
Parent(s) or Guardian(s):
Where Employed and Position:
_________________________________
__________________________________________
_________________________________
__________________________________________
Brother(s) and/or Sister(s) and Age:
______________________________________________________________________________
How many in your family will be attending college next year (include yourself)? ___________________
Name of college, university, junior college or
technical school you plan to attend: (List top three choices
in order of
preference.)_____________________________________________________________
______________________________________________________________________________
Intended field of study:_____________________________________________________________
High School Employment:
Name of Employer
Type of Employment
Length of Employment
__________________________
___________________________
_________________
__________________________
___________________________
_________________
__________________________
___________________________
_________________
__________________________
___________________________
_________________
Athletic Involvement and
Honors:
Clubs,Organizations,
# of Years
# of
years
Leadership
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Community Service: # of Years
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Have you been involved in the music program at El Molino? Yes_____ No_____ If yes, please explain.____________________________________________________
Religious affiliation: (Optional)
_______________________________________________________
Are you related to a veteran of a foreign war? Yes___________
No___________ If yes, what is the relationship?
_________________________________________________________
Any members of the Italian Catholic Federation in your family? If so, who? ______________________
Any additional information that might be
helpful (Special circumstances, significant activities not covered
above, anything else you would like us to
know):__________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_______________________________________________________
Please attach a brief (maximum 1 page), typed,
autobiographical statement.
Include information that will help the reader know you better.
You might want to include experiences and interests that led to your
choice of course of study, educational and career goals and a
description of yourself.
To my knowledge, the information above is correct and complete. I am aware that information may be released to community members as part of the evaluation process for specific local scholarships.
Student’s signature______________________________________________________________
Parent’s/Guardian’s signature______________________________________________________
Completed Local
Scholarship forms are due to Debbie Demeduc by October 31, 2011
We will be unable to accept applications after this date.