2016 David Robben Memorial Scholarship
APPLICATION FORM
2016 DAVID ROBBEN MEMORIAL SCHOLARSHIP
Administered by the Solano Community Foundation
Please type the information requested in the space provided unless asked to provide your responses using a separate sheet of paper.
Submit this completed and signed application and all supporting documents to the Dixon High School Counseling Center.
All information provided will be held strictly confidential.
Your First Name: / Your Last Name:Home Address: / Student DOB:
City, State, Zip: / Gender:
Email address: / Phone No.:
Overall weighted GPA at Dixon High School: / (Attach your Official H. S. Grade Transcript)
List the name(s) of the University of California Campus you have applied to. / Have you been accepted?
1. / Yes / No
2. / Yes / No
3. / Yes / No
List the names of the three Dixon H.S. faculty who have written a letters of recommendation on your behalf. / What subject(s) do they teach?
1.
2.
3.
PERSONAL INTEREST ESSAY QUESTIONS – Please type your responses on a SEPARATE SHEET of paper.
A. Describe your particular areas of academic interest (i.e. physics, biology, chemistry, history, economics, electrical, mechanical or civil engineering, math, computer engineering, English, literature). What are you interested in studying at University? Have you decided on a major, or have an anticipated degree in mind?
Label as “Response to Question A.”
B. List and describe both school-related and non-school activities or programs in which you have participated during the past two or three years. Include volunteer work and paid employment (include positions held, work performed, and experience gained). Any sports teams, clubs, or service organizations? Any particular accomplishments?
Label as “Response to Question B.”
C. Have you traveled to any interesting places? Were you an exchange student during high school, and if so where and for how long? How do you feel you’ve benefited from your travel experience(s)?
Label as “Response to Question C.”
FINANCIAL NEED QUESTIONS – Please type your responses on a separate sheet of paper.
D. Explain your understanding of your family's financial situation, and how much aid they may be able to provide for you to attend University. If you have held a paid job(s) in the last two years, how much did you earn and how much money have you saved? Are there relatives or family members able to contribute to your education? Label as “Response to Question D.”
NOTE: If your living expenses can be covered you may not have to work and can devote more time to your studies (remember, you must be a full-time student and graduate in 4 years to retain your scholarship).
E. List the name and amount of any other assistance and financial aid (scholarships, grants, or awards) which you have applied for, and the amount awarded, or the amount you may receive.
Label as “Response to Question E.”
F. How many children and adults are there in your household (living at home) and what are their ages? Including you, how many already are, or will be attending college next school year? Please provide the names, phone numbers, and residence addresses of your Father /Mother/Guardians. Include their current occupations along with name and location of their place(s) of employment. Label as “Response to Question F.”
G. Attach copies of pages 1 and 2 of your parents/guardian’s most recent Federal Tax Return (IRS Form 1040).
If you have filed your own tax return, provide a copy.
NOTICE OF PRIVACY AND CONSENT
At times it is necessary to request enrollment status from your student’s high school or college so that we can make or continue to provide scholarship award payments, and to maintain contact with Solano Community Foundation scholarship recipients. Please read the following information carefully.
Privacy Act Statement of 1974. States “No agency shall disclose any record which is contained in a system of records by any means of communication to any person, or to another agency, except pursuant to a written request by, or with the prior written consent of, the individual to whom the record pertains, unless disclosure of the record would be to those officers and employees of the agency which maintains the record and who have a need for the record in the performance of their duties.”
Consent to Disclose Information. By signing this document you hereby grant permission to the Solano Community Foundation (SCF) to share and disclose personal and financial information with the members of the SCF Grants Committee and the Scholarships Selection Committee. Scholarship applications will be reviewed by Committee members and with SCF staff who process scholarship award payments. The SCF Board of Directors has final approval of Scholarship Selection Committee recommendations for awards.
CERTIFICATION & SIGNATURES
My parent/guardian and I certify and understand that: / Parent Initials / Student Initials1. The information provided in this application is complete and may be verified for accuracy.
2. The falsification of any application information may result in not being considered for an interview, non-selection as a recipient, non-payment of an award if selected, or termination and reimbursement of any payment made.
3. That we have read the Privacy Act Statement and Consent to Disclose Information paragraphs above and give our consent for SCF to use information provided in this scholarship application only for the purposes of scholarship selection and award of payment.
4. If awarded this four year scholarship, the applicant agrees not to take out any student loans.
Student/Applicant Signature: / Date:
Parent/Guardian Signature: / Date:
Rev. 2-16-2016 Page 2 of 2