2018 Patron Scholarship Program Application Form

2018 Patron Scholarship Program Application Form

Applicant Information
Name / First: / Last: / Middle Initial:
Preferred first name, if different from the above:
Date of Birth (mm/dd/yy)
Address
Contact Details / Email: / Phone:
Parent or Guardian Information
Name / First: / Last: / Middle Initial:
Patron Dairy name and number
Location
Contact Details / Email: / Phone:
Applicant High School Information
School Name
Graduation Date (mm/yy)
Address / Street: / City: / State: / Zip:
Post-Secondary School Data
Nameofpost-secondaryschool that youplantoattend.(Ifunknown,pleaselist the schoolsthat youhaveapplied to,inorderof preference.)Please use officialschoolnames.
School Name: / City: / State:
School Name: / City: / State:
School Type / ☐4 Year College or University ☐2 Year Community or Junior College
☐Vocational-Technical School ☐Other, please explain
Major/Course of Study Anticipated / Graduation Date (mm/yy):
Student Will: / ☐Live On Campus / ☐Live Off Campus / ☐Commute From Home
If school choice is a public institution, applicant will pay / ☐In-State Resident Tuition / ☐Out-Of-State Tuition
Essay
Please submit a one page written essay explaining your career and educational aspirations. Your essay will be reviewed by a blind Selection Committee, and will be one of the most important factors in the evaluation of your application.
Extra Curricular Activities, Leadership, Honors and Awards
Activities / Listallschoolactivitiesinwhichyouhaveparticipatedduringthepastfouryears(e.g.student, government,music, sports,etc.).
Grade / 9 / 10 / 11 / 12
Leadership / List allcommunityactivitiesinwhichyouhaveparticipated withoutpayduringthepastfouryears, e.g. Boy/GirlScouts,hospitalvolunteer,SpecialOlympics).
Grade / 9 / 10 / 11 / 12
Special Awards,
Honors / Indicateallspecialawards,honorsand offices you’ve held.
Work Experience
Describeyourworkexperienceduringthepastfouryears.Indicate dates ofemploymentineachjobandapproximatenumberofhoursworkedeach week. Listamountsearnedat eachjob.
Company/Position / Start Date (mm/yy) / End Date
(mm/yy) / Hours per Week / Amount Earned
Unusual Circumstances
Pleasedescribehowandwhenanyunusualfamilyorpersonalcircumstanceshaveaffectedyourachievementin school,workexperience,oryourparticipationinschoolandcommunityactivities.
Other Scholarships
Pleaselistbelowthenameandamountofanygrants orscholarships youhavebeenawardedforthecomingyear.
Name of Award / Amount / Check One
$ / ☐Granted ☐Pending
$ / ☐Granted ☐Pending
Applicant Appraisal (Required)
To be completed by a high school counselor or advisor, an instructor, or a work supervisor who knows you well.
High school counselor or advisor, an instructor, or a work supervisor: You have been asked to provide information in support of this application. Please give immediate and serious attention to the following statements. When complete, please return to applicant or photocopy this section and return to applicant in a sealed envelope.
The applicant’s choice of post-secondary educational program is / ☐Extremely Appropriate / ☐Very Appropriate / ☐Moderately Appropriate / ☐Inappropriate
The applicant’s achievements reflect his/her ability / ☐Extremely Well / ☐Very Well / ☐Moderately Well / ☐Not Well
The applicant’s ability to set realistic and attainable goals is / ☐Excellent / ☐Good / ☐Fair / ☐Poor
The quality of the applicant’s commitment to school and
community is / ☐Excellent / ☐Good / ☐Fair / ☐Poor
The applicant is able to seek, find, and use learning resources / ☐Extremely Well / ☐Very Well / ☐Moderately Well / ☐Not Well
The applicant demonstrates curiosity and initiative / ☐Extremely Well / ☐Very Well / ☐Moderately Well / ☐Not Well
The applicant demonstrates good problem-solving skills, follows through, and completes tasks / ☐Extremely Well / ☐Very Well / ☐Moderately Well / ☐Not Well
The applicant’s respect for self and others is / ☐Excellent / ☐Good / ☐Fair / ☐Poor
Comments:
Appraiser’s Name
Title
Contact Details / Email: / Phone:
Appraiser’s Signature
Appraiser’s Address
Transcript Information (Required)
You must include a current high school transcript of grades and have the following section completed by the appropriate school official. (A clear explanation of the school’s grading scale must also be submitted.)
Applicant Ranks: In a class of:
Cumulative Grade Point Average (through December 2017) /4.0 scale
School Official’s Signature
Date: / Title: / Phone Number:
School Official’s Address
Application Submission
Your scholarship application is not complete and will not be considered until you have returned all of the items on the below checklist.
Student Application Form / ☐ /
Current Transcript of Grades / ☐ /
Submission Address / Glanbia Nutritionals,
Mike Machado, (attn. Patron Scholarship)
121 4th. Ave. S
Twin Falls, ID 83301
All materials must be submitted on time. The post mark deadline is May, 28th.
In submitting this application, I certify that the information provided is complete and accurate to the best of my knowledge. If requested, I agree to give proof of the information that I have given in this form. Falsification of information may result in termination of any scholarship granted. Once submitted, this application becomes property of Glanbia Nutritionals.
Applicant’s Signature / Date:
Parent/Guardian Signature / Date: