Lilly Endowment Community Scholarship Program

Study Off-Campus Program Eligibility Review

Turn in at least one semester prior to semester off campus

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 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.

Scholar’s Name______

Entering Cohort Year______Telephone Number (____)______

Student’s Email (notification will be sent here) ______

Community Foundation______

Home College/University______

Name of Off Campus Program______

Dates of Off Campus Program (example January-June, 2013) ______Credits ______

Check below if you can respond “Yes”

___ This off-campus program is approved by my home college.

___ Program costs will be billed directly through my home college invoice.

___ Credits will automatically transfer to my academic records upon program completion.

___ Detailed estimated costs are attached. (Will not cover travel, room, or board.)

This form must be signed by a program representative of the home campus and by the Lilly Scholar indicating the accuracy of the information provided.

Program Representative’s Signature ______

Title ______Telephone (______)______

Lilly Scholar’s Signature ______Date)______

Return to: or

Lilly Endowment Community Scholarship Program

Independent Colleges of Indiana, Inc., 30 S. Meridian Street, Suite 800, Indianapolis, Indiana 46204

Questions: Mary Dickerson, Director of Programs, LECSP, at (317) 684-4297 or . ______

For Office Use Only

This off campus study program is approved as described above: Yes No

Scholar & Community Foundation Notified ______Database Updated ______

LECSP Representative ______

1/22/2015