James Madison Memorial High School Local Scholarships Application

James Madison Memorial High School Local Scholarships Application (SUBMIT NO LATER THAN: FRIDAY, JANUARY 9, 2015.

Last Name: ______First Name:______Student ID Number: ______

E-mail address (VERY IMPORTANT IF WE NEED TO CONTACT YOU) ______Your cell # (VERY IMPORTANT IF WE NEED TO CONTACT YOU) ______

Student lives with: ___both parents ___parent/step-parent ___mother ___father ___guardian ___other

Parent/Guardian names: ______

Parent/Guardian occupations: ______

Parent/Guardian place of employment: ______

Names/ages of brothers/sisters: ______

Total number of brothers/sisters living with you at home: ______

Colleges you hope to attend: (1st choice) ______(2nd choice) ______

Probable college major(s): ______Career(s) that you are considering: ______

Summit Credit Union Member Yes No

Are you in the UW PEOPLE Program? Yes No ITA Program? Yes No

Participation in Sports/Clubs/Organizations: (any participation from grade 9 thru grade 12) Sport/Club/Organization: Month(s)/Year(s) that you were Were you an officer or leader? active:

Part time jobs you have held during grades 9 – 12: Employer name: Job Title: Approximate months Approximate hours per worked (From __ to __) week:

Community Service: Unpaid Service Performed To Benefit Others at School or in the Community: Description of the Month(s)/Year(s) that you TOTAL number of Were you an activity (Please be performed the service: hours of service officer/leader? specific.)

Are there any other examples of your leadership or service, not detailed above, that you’d like to describe here?

Do you have any kind of physical disability or learning disability? (Explain briefly)

Are there any special circumstances or hardship you’d like us to consider? (death of a parent, illness, loss of job)

The Memorial Scholarship Committee has several scholarships that are based on financial need. If you wish to be considered for these, you must provide the following information.

Parent’s “adjusted gross income” from line 32 of tax form 1040: ______Do you qualify for free/reduced lunch? ______Number of your bro/sisters also in college next year? ______

If parents are separated, do you receive financial support from both of them? ______

Personal Statement Required: Attach a one page statement about: “What I’d like the Scholarship Committee to know about me.” Reporting Responsibility: Between now and graduation, if you are notified that you will be receiving any other scholarship, you must notify JMM Scholarship Committee Chair, Dan Maloney, in the Student Services Office.

DEADLINE FOR THIS FORM: THIS FORM MUST BE SUBMITTED TO STUDENT SERVICES, ALONG WITH THE PERSONAL STATEMENT, NO LATER THAN FRIDAY, JANUARY 9, 2015