<p> Lilly Endowment Community Scholarship Program Study Off-Campus Program Eligibility Review Turn in at least one semester prior to semester off campus</p><p>All scholars wanting to apply their Lilly Community Scholarship to an off-campus study program are required to submit this form to Independent Colleges of Indiana prior to signing any contracts or paying required deposits for participation in an off-campus program. If the program is eligible, your Lilly Endowment Community Scholarship will cover tuition and academic fees billed through your university/college up to the cost of the semester tuition at your home campus. Travel, food, lodging, and other costs are not covered by this scholarship program. The student and the community foundation will be notified of the off- campus study program’s eligibility for scholarship funding via email.</p><p>Scholar’s Name______</p><p>Entering Cohort Year______Telephone Number (____)______</p><p>Student’s Email (notification will be sent here) ______</p><p>Community Foundation______</p><p>Home College/University______</p><p>Name of Off Campus Program______</p><p>Dates of Off Campus Program (example January-June, 20--) ______Credits ______</p><p>Check below if you can respond “Yes” ___ This off-campus program is approved by my college/university. ___ Program costs will be billed directly through my home college/university invoice. If not, please explain billing arrangement: ______Credits will automatically transfer to my academic records upon program completion. ___ Detailed estimated costs are attached. (Will not cover travel, room, or board.)</p><p>This form must be signed by a campus program representative and by the Lilly Scholar indicating the accuracy of the information provided.</p><p>Campus Representative’s Printed Name ______</p><p>Campus Representative’s Signature ______</p><p>Title ______Telephone (______)______</p><p>Student’s Signature ______</p><p>Return to: [email protected] or </p><p>Lilly Endowment Community Scholarship Program Independent Colleges of Indiana, Inc., 30 S. Meridian Street, Suite 800, Indianapolis, Indiana 46204</p><p>Questions: Mary Dickerson, Director of Programs, LECSP, at (317) 684-4297 or [email protected]. </p><p>______For ICI Office Use Only</p><p>This off campus study program is approved as described above: Yes No Scholar & Community Foundation Notified ______LECSP Staff ______Database Updated ______4/6/2018</p>