The Brick Church Women S Association

APPLICATION FOR SCHOLARSHIP AID Please answer every question legibly and fully. If there is information about you or your family which would be important for the committee to consider that is not covered by this questionnaire please include on a separate piece of paper. Completed applications and recommendations should be returned to the Brick Presbyterian Church, 62 East 92nd Street, New York, NY 10128, attention Carol Ann Mercer by May 5, 2014 Date: ______PERSONAL

Name: ______Date of Birth:______Sex: ____

Address: ______Telephone: ______(number, street, apt) ______(city) (state) (zip) Father’s Name: ______Living or Deceased:______

Address: ______(number, street, apt) (city) (state) (zip)

Mother’s Name: ______Living or Deceased:______(number, street, apt) (city) (state) (zip)

Brothers and Sisters ______

Ages ______

CHURCH AFFILIATION Member of what church? ______

If not a member of The Brick Church, are you involved in any Brick Church programs, employed by Brick Church, or related in any other way? Please note how long you have had this relationship with the Church.

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Although not required, you may include a letter of reference from a program leader or other individuals you may have worked with at Brick Church. ACADEMIC

Name of school currently attending: ______Grade: ____

Address of school: ______

How long have you attended this school?______

What school did you attend before? ______

Academic honors at school: ______

Extra-curricular interests: ______

______

Employment while in school: ______

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Please attach transcripts of grades, testing scores, and one letter of recommendation from the school principal, guidance advisor, or an interested teacher.

FINANCIAL (CONFIDENTIAL)

Father’s occupation: ______

Father’s current employer: ______(name of company) (address)

Length of employment: ______Prior employer if less than two years:______

Father’s yearly income: Salary: ______Bonuses: ______

All other income: Dividends: ______Interest: ______

Soc. Security: ______Pension: ______

Welfare: ______Veteran’s Benefits: ______

Other: ______Total: ______

Other assets: Apartment: ______Car: ______

Second home: ______Other: ______Mother’s Occupation: ______

Mother’s current employer: ______(name of company) (address)

Length of employment: ______Prior employer if less than two years:______

Mother’s yearly income: Salary: ______Bonuses: ______

All other income: Dividends: ______Interest: ______

Soc. Security: ______Pension: ______

Welfare: ______Veteran’s Benefits: ______

Other: ______Total: ______

Other assets: Apartment: ______Car: ______

Second home: ______Other: ______

EXPENSES Number in household: Children at home and ages: ______

Elderly at home: ______

Children away at school and ages: ______

Major medical or dental bills: ______

SCHOLARSHIP AID Are you currently on scholarship or receiving any financial aid? ______

From whom, when due, and amount: ______

______

Have applied for other scholarship aid? Please describe: ______

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______Have you worked during the school year and/or in the summer to earn money for your education?

Please describe all jobs: ______

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Please list anticipated expenses for the year and itemize (room, board, tuition, books, etc):

______

What degree or certificate will you be working on during the coming school year?

______

Colleges or schools applied to:

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