Edgar and Lucile Schergens Foundation Scholarship Application STUDENT INSTRUCTIONS READ ALL INSTRUCTIONS BEFORE FILLING OUT APPLICATION. 1. If you fill out your application by computer, Do Not change the font style or size. If you are using a typewriter, please use 12 pt. Times Roman or Arial, 12 pt. Do Not use Script if at all possible. 2. Please read each question or request for specific information carefully. There are instances on the application where more than one piece of information is requested per line. (i.e. Parent Information. The line asks for the name of father/stepfather/guardian. It also asks you to check one. You must indicate whether the name you have just entered is the father, stepfather or guardian.) 3. Make sure all check boxes that apply have been checked. 4. Please note that there are separate sections for summer employment experience and employment held during the school (academic) year. 5. Please note that there are separate sections for extracurricular activities. There is one section for school related sports, band or choir; one section for clubs and club activities associated with your school; and one section for volunteer work outside of school related activities. In each of these sections there is a column for number of years of participation and a column for awards, honors and/or offices held. There should be no need to attach additional pages dividing your activities by freshman, sophomore, junior or senior year. 6. Confine your essay to the space allowed on the application. Do Not attach extra pages. 7. Check to make sure all signatures are in place. 8. Do Not bind the application or put it in a folder or enclosure. 9. Do Not attach letters of recommendation, leaflets or bound material. All the information needed by the Scholarship Committee is on the application itself. If you read the directions carefully, you should be able to relate all pertinent information on the application. Do, however, feel free to relate further information to the committee at your interview should you feel it necessary. 10. When finished give your completed application to your guidance counselor. He/she will fill out their appropriate section, attach your grade transcript and deliver it to the Scholarship Committee.
Edgar and Lucille Schergens Foundation Scholarship Application APPLICANT INFORMATION: Last name, first name, middle initial Address, city, state, zip Area code and phone number Date of Birth Email address PARENT INFORMATION: Name of father / stepfather / guardian (please check one) Address, city, state, zip Name of mother / stepmother / guardian (please check one) Address, city, state, zip (if different than listed above) Name of spouse (if applicable) Check (if applicable) Father deceased Mother deceased Parents Divorced CERTIFICATION: I (we) hereby affirm that the information provided in this application is accurate and complete to the best of my (our) knowledge. I (we) agree to give my (our) consent for school counselors/school officials to provide information for consideration in the selection process. Applicant s parents or legal guardians must also sign this certification unless the applicant is legally classified as an independent student. (Contact the United States Department of Education for the definition of an independent student. Check here if applicant is an independent student. Applicant s signature Father s signature Mother s signature Guardian s signature (if applicable) Note: Changes to the application form are not permitted and will be cause for rejection of scholarship consideration.
HIGH SCHOOL INFORMATION: School name and city Principal s name Graduation year Telephone number POST HIGH SCHOOL INFORMATION: (if applicable) GED testing site Date of GED Certificate GED Instructor s name COLLEGE/CAREER INFORMATION: List the name of the school at which the scholarship would be used if awarded. If unknown, please list, in order of preference, schools to which you have applied or will be applying. College/university name, city and state College/university name, city and state College/university name, city and state Major course of study planned Accepted Accepted Accepted Anticipated date of college graduation (mo/yr) Professional/vocational interest (Indicate your choice of life work Please check all that apply: 4-yr college/university 2-yr college/university Full time Part-time Other WORK EXPERIENCE: SUMMER EMPLOYMENT Describe your paid work experience over last 4 years. Employer and Position/Nature of Work Year of high school participation (i.e. freshman, sophomore, etc) # of s Hours per WORK EXPERIENCE: ACADEMIC YEAR EMPLOYMENT Describe your paid work experience over last 4 yrs. Employer and Position/Nature of Work Year of high school participation (i.e. freshman, sophomore, etc) # of s Hours per PAGE 2
If you are currently working, why do you work? If you are not employed, why not? PERSONAL STATEMENT: Using the space provided below, briefly state the reasons you feel you are deserving of this scholarship. ACTIVITIES, AWARDS, AND HONORS: Using the space provided below, list all school and community activities in which you have participated during the past four years, i.e., student government, sports, choir, band, church work, volunteer work, etc. Sports/Band/Choir # Years of Participation # Hours per Leadership Positions/ Awards/Honors/Offices Held School Clubs/Club Projects (incl. club project hours with associated club) # Years of Participation # Hours per Leadership Positions/ Awards/Honors/Offices Held Page 3
Non-School/Volunteering (i.e., church work, community, etc.) # Years of Participation # Hours per Leadership Positions/ Awards/Honors/Offices Held UNUSUAL CIRCUMSTANCES: REPORT ANY FAMILY, PERSONAL, OR FINANCIAL CIRCUMSTANCES WHICH YOU THINK WARRANT CONSIDERATION. Unusual circumstances may be considered only in the event of a tie between applicants. TRANSCRIPT INFORMATION: (to be completed by guidance counselor or appropriate official). Attach your most recent official high school, home school or GEC transcript (do not send separately). Your transcript must be an official certified copy from your school/institution. Applicant Ranked in a class of Cumulative GPA SAT Verbal/Critical Reading SAT Math SAT Writing SAT Total ACT Composite Score SAT Selection Index Core 40 College Prep Curriculum Yes No Academic Honors Diploma Candidate? Yes No Are grades weighted? Yes No School official s name and title School official s signature Date City, State, Zip NOTE: Changes to the application form are not permitted and will be cause for rejection of scholarship consideration. Page 4
Essay: In the space provided below please type an essay entitled "Goals and Aspirations for the Future". The line spacing is already set within the space provided (double). Please do not change the font size if completing the essay on a computer. Please confine your essay to the space below (However, no less than 300 words). Please do not add extra pages.