<p> THE HENRY KITCHENS SCHOLARSHIP PROGRAM</p><p>I. ABOUT THE SCHOLARSHIP PROGRAM This Scholarship program was established in 1963 at the First United Methodist Church of Newnan in memory of the late Henry B. Kitchens, who taught the Henry Kitchens Sunday School Class for many years.</p><p>II. WHO MAY APPLY FOR THE SCHOLARSHIP? Any graduate of a public or private school within Coweta County.</p><p>III. CRITERIA FOR THE SELECTION OF THE RECIPIENTS: The awards from this program are based on several aspects of the applicant’s educational, family, and personal background. However, the major components which are used by the Scholarship Committee are as follows:</p><p>A. Financial Needs of the Applicant: (per capita income of the family---adjusted gross income divided by the number of dependents.) B. Academic Record of the Applicant: (GPA & SAT scores) C. Extracurricular Activities: (Clubs, Sports, Music Programs, Work Experiences, Community/Church Activities.)</p><p>IV. AMOUNT OF THE AWARDS: The amount of the individual awards may vary each year, as determined by the Scholarship Committee. </p><p>V. MATERIALS TO BE SUBMITTED TO YOUR SCHOOL COUNSELOR:</p><p>1. A Completed Scholarship Application (see attached).</p><p>2. A copy of the first page of your parents’ most recent Federal Tax Return, showing their income, dependents, and adjusted gross income. In the event your parents are separated or divorced, please submit the financial information on each parent, along with a statement regarding the amount of child support received on your behalf each year.</p><p>3. A transcript of your academic record through the first semester of your senior year showing subjects, grades, GPA, rank in class. </p><p>4. SAT scores.</p><p>5. A recent and clear photo of yourself.</p><p>NOTE: INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED BY THE SCHOLARSHIP COMMITTEE.</p><p>1 APPLICATION FORM FOR THE HENRY KITCHENS SCHOLARSHIP</p><p>Applicant______School______</p><p>Home Address______</p><p>Telephone ______Sex: ______Date of Birth______</p><p>Father ______Occupation______</p><p>Address (if different from above)______</p><p>Mother ______</p><p>Address (if different from above)______</p><p>List colleges, universities, and schools to which you have applied and indicate the current status of your applications: (Accepted, Not Accepted, Pending, etc.)</p><p>INSTITUTIONS STATUS</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Have you completed the Financial Aid Form? _____ Have you been assured of financial assistance? ______If so, please list below the source and amount to be received:</p><p>SOURCE AMOUNT</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>2 List any significant work experiences (employed or volunteer work) which you have had for the past three years during the school day, after school, or summer. Also, indicate the length of time employed at each job.</p><p>______</p><p>______</p><p>______</p><p>List the major clubs and school activities (sports, music programs, etc.) in which you have participated, both within the school and the community. Also, indicate offices, titles, positions, etc. held, as applicable.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>What significant achievements or honors have you received during the past three years?</p><p>______</p><p>______</p><p>______</p><p>______</p><p>List any special circumstances within your family: such as, single parent who is the main financial provider in the household; other siblings who are in college; unusual medical expenses, etc.</p><p>______</p><p>______</p><p>______</p><p>______</p><p>3 ______In the space provided below, make a brief statement in your own handwriting, concerning your future educational and career plans:</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>In order for the school to release school records, test scores, tax information from parents, etc. and other data requested in this application, please sign this form below as indicated.</p><p>Applicant’s signature: ______Date: ______</p><p>Parent’s signature: ______Date: ______</p><p>4 Note: Please return completed application and attachments to your school counselor by the date announced. Incomplete applications will not be reviewed by the Scholarship Committee. SCREENING SCALE FOR SELECTION OF SCHOLARSHIP RECIPIENTS (For use only by Scholarship Committee & School Counselors)</p><p>In order to establish a uniform and impartial method of selecting recipients for scholarship awards, the following scale should be used as the initial screening device.</p><p>Student Name ______School______</p><p>Category Points</p><p>1) Financial Needs (Per Capita Income of family)* (1-5) _____ 2) Academic GPA (1-5) _____ 3) ++SAT Scores or ACT (Composite Scores) (1-5) _____ 4) Extracurricular Activities** (1-3) _____</p><p>Subtotals _____</p><p>5) Special Circumstances within the Family: (0-3) _____ (See page 3 of application form)</p><p>TOTAL POINTS _____</p><p>* (1) Adjusted gross income of family divided by the number of dependents as shown on current Federal Income Tax Returns. (Note: Point Scale below)</p><p>**(4) Major extracurricular activities: varsity sports, cheerleading, band, chorus, club officer, work experiences, community/church activities, etc.: (3 points)</p><p>***Approximate percent per category: Financial Needs, 24%; GPA, 24%; SAT, 24%; Extra Curricular, 14%; Special Circumstances, 14%.</p><p>POINT SCALE</p><p>GPA SAT ACT Points Per Capita Income 95 -100 2200-2400 33-36 5 9,000/below 90 - 94 1900-2199 29-32 4 10,000-12,000 85 – 89 1600-1899 25-28 3 13,000-15,000 80 – 84 1300-1599 21-24 2 16,000-18,000 75 – 79 1000-1299 17-20 1 19,000-20,000 ------</p><p>++Note: Combined scores of SAT: Critical Reading, Math, and Writing)</p><p>NOTE: All pages of Scholarship Application (pages 1-5) updated, April 2012.</p><p>5 All forms printed prior to this date are obsolete.</p><p>6</p>