<p> James Madison Memorial High School Local Scholarships Application (SUBMIT NO LATER THAN: FRIDAY, JANUARY 9, 2015.</p><p>Last Name: ______First Name:______Student ID Number: ______</p><p>E-mail address (VERY IMPORTANT IF WE NEED TO CONTACT YOU) ______Your cell # (VERY IMPORTANT IF WE NEED TO CONTACT YOU) ______</p><p>Student lives with: ___both parents ___parent/step-parent ___mother ___father ___guardian ___other</p><p>Parent/Guardian names: ______</p><p>Parent/Guardian occupations: ______</p><p>Parent/Guardian place of employment: ______</p><p>Names/ages of brothers/sisters: ______</p><p>Total number of brothers/sisters living with you at home: ______</p><p>Colleges you hope to attend: (1st choice) ______(2nd choice) ______</p><p>Probable college major(s): ______Career(s) that you are considering: ______</p><p>Summit Credit Union Member Yes No</p><p>Are you in the UW PEOPLE Program? Yes No ITA Program? Yes No</p><p>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:</p><p>Part time jobs you have held during grades 9 – 12: Employer name: Job Title: Approximate months Approximate hours per worked (From __ to __) week:</p><p>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.)</p><p>Are there any other examples of your leadership or service, not detailed above, that you’d like to describe here?</p><p>Do you have any kind of physical disability or learning disability? (Explain briefly) </p><p>Are there any special circumstances or hardship you’d like us to consider? (death of a parent, illness, loss of job)</p><p>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.</p><p>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? ______</p><p>If parents are separated, do you receive financial support from both of them? ______</p><p>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.</p><p>DEADLINE FOR THIS FORM: THIS FORM MUST BE SUBMITTED TO STUDENT SERVICES, ALONG WITH THE PERSONAL STATEMENT, NO LATER THAN FRIDAY, JANUARY 9, 2015</p>