Applicant Name: ______

Date: ______

Osage Scholarship Application

The following local organizations use this scholarship application form. Decide upon the scholarships for which you would like be considered. If you are applying for more then one scholarship, make a copy of the entire application for EACH scholarship. Each front page should have only one scholarship checked. Complete the application using Microsoft Word.

_____ Kiwanis Club Scholarship

_____ Lions Club Scholarship

_____ Rotary Club Scholarship

_____ Marian Stibal Memorial Scholarship (for those planning to teach)

_____ Norbert Mullenbach Memorial Scholarship

_____ Osage Education Association Scholarship (for those planning to teach)

_____ Osage Chamber of Commerce Scholarship

_____ Osage Education Foundation Scholarship

_____ Raub Scholarship (four year college program & 3.0 GPA)

_____ Francis Jeffries Scholarship (preference to students attending University of Iowa)

_____ Steven Funk Scholarship (applicants must demonstrate exemplary academic credentials coupled with broad-based participation in school and community activities)

updated 12/12/2011


OSAGE SCHOLARSHIP APPLICATION

Complete this application using Microsoft Word or other word processing program.

General Information

Your Name (Last, First, Middle Initial): /

Address:

County:

Telephone Number:
Mother’s Name:
Father’s Name:

How many years have you resided in Iowa? _____

Have you ever been convicted of a misdemeanor or felony, excluding minor traffic violations? Yes / No

Have you served ineligibility due to a violation of the District’s Good Conduct Policy? Yes / No

Have you ever had an In-School or Out-Of-School Suspension? Yes / No

If yes to any of these, please explain.

College Plans

Name of School:
City and State of School:
Are you accepted at the college?
Yes___ No___
Intended degree or program :
(check all that apply)
Certificate or Diploma program ___
Associate Degree or two year program ___
Bachelor’s Degree or four-year program___
More than a Bachelor’s Degree ___
Other ___
Major field/area of study: / Semesters of core, college prep courses
grades 9-12:
Math ____
Science ____
English ____
Social Studies ____
Foreign Language ___
Semesters of elective courses grades 9-12: ____
Number of college credits earned while in high school ______


Applicant Name: ______

School Activities

In the table below, list all school activities (athletics, clubs, special music groups, etc.) for grades 9-12, including this spring and summer. DO NOT include Little Brother/Sister on this page.

Years / Extracurricular Activity/Group / Honors Received / Offices Held
4 / High School Chess Club / President- 1 year
1st place at districts- 2 years

Adjust or add page(s) as needed


Applicant Name: ______

Work Experience

Record work experience in grades 9–12, including summers. Add up total hours worked per job to March 1 of this year and include on this application. DO NOT include job if hours per week are over 40 during the school year.

Employer

/ Position / From
(Mo/Yr) / To
(Mo/Yr) / Total
Hours
A & W / Dishwasher / 6/2009 / 9/2010 / 480

Community Involvement/Volunteer Service

List community involvement while in grades 9-12. Examples of involvement may include: Scouts, church, Little Brother/Sister program, 4-H, and helping community organizations such as the Bloodmobile, Rotary, etc... Include summer work experience and the average hours per week for any ongoing project. Write down the total hours per project up to March 1 of this year.

Organization / Project / Date: (Mo/Yr) / Total Hours
4-H / Sock Sale / 10/2011 / 2

Adjust or add page(s) as needed
Applicant Name: ______

Goals

Type a statement about your career and educational goals and explain why you chose the field or major area of study. What sort of advantages and disadvantages do you foresee facing as you work toward your goals? (500 words minimum)

Unusual Circumstances

In the space below, type your comments on any reasons or hardships that may have prevented you from earning more points in other categories. Make additional comments that may be relevant for committee consideration.


Certification

I certify that the information provided is accurate and complete to the best of my knowledge. I give the scholarship committee permission to verify any information on this application. I understand that any false information may disqualify me from a scholarship.

Scholarships are given as free grants with no obligation to be repaid. This money was made available through the generosity of past Osage graduates and other donors. I understand that the scholarship committee would like me to consider making a contribution to the scholarship fund sometime in the future when I am financially able.

Signature of applicant ______date ______

Signature of parent/guardian______date ______

DO NOT WRITE BELOW THIS LINE

______

Completed application turned in by deadline. Yes___ No ___ Due ______

Character ______
Attendance ______
Academics ______
School Activities ______
Work Experience ______
Community/Volunteer ______
College Plans ______
Goals ______
Unusual Circumstances ______
Interview ______
Total Points ______
/ Number of days absent for seven semesters______
Number of times tardy for seven semesters______
Latest ITED Composite Iowa School %tile ______
Seventh semester total grade points ______
Cumulative GPA for seven semesters ______
Seventh semester class rank ______