HENRYCOUNTY

COMMUNITY FOUNDATION, INC.

LILLY ENDOWMENT

COMMUNITY SCHOLARSHIP

THIS SCHOLARSHIP IS DESIGNED TO RAISE THE LEVEL OF EDUCATIONAL ATTAINMENT IN HENRY COUNTY BY ENCOURAGING MORE STUDENTS TO ATTEND COLLEGE, GRADUATE, AND INCREASE THE PERCENTAGE OF INDIANA RESIDENTS WHO HOLD A BACCALAUREATE DEGREE.

Scholarship Information

The Lilly Endowment Community Scholarship will fund full tuition, required fees, and an allocation of up to $900 per year for required books and required equipment for four years of undergraduate study leading to a baccalaureate degree in any Indiana public or private college or university accredited by the North Central Association of Colleges and Schools.

Applicant must be:

•Resident of HenryCounty

•2017 graduate of one of the following seven high schools: Blue River Valley Jr-Sr High School, Hagerstown Jr-Sr High School, Knightstown High School, New Castle High School, Shenandoah Jr-Sr High School, Tri Jr-Sr High School, Union Jr-Sr High School

•Accepted to a full-time baccalaureate course of study beginning in the fall of 2017 at an accredited public or private college or university in Indiana

The student who receives this scholarship must:

•Remain in good standing at the college or university s/he attends

•Agree to report annually to the Henry County Community Foundation, Inc. on his/her

progress in college

•Submit an official academic transcript to the Foundation by May 31st each year.

•Agree to report annually to the Foundation for a period of ten years following graduation

on his/her employment and/or additional education

Due date: The completed application must be returned to your High School Guidance Office

by SEPTEMBER 23, 2016 .

HENRY COUNTY

COMMUNITY FOUNDATION, INC.

LILLY ENDOWMENT COMMUNITY SCHOLARSHIP APPLICATION

Personal Data

(Please type or print the following data)

Name Date of Birth / /

Permanent mailing address

City State Zip

Phone ( ) Email

Cell Phone ()Social Security Number XXX-XX-

Parent(s)/Guardian(s)

Relationship to applicant

High School

Address

City State Zip

Graduation date: month year

4-year Indiana college or university

Major course of study

Housing plans: on campus off campus commute

Work experience:List places of employment over last four years, approximate hours worked weekly.

CompanyDates (from/to)Hrs per week

Special awards/recognition & activities: List all school activities & honors over past four years.

Extracurricular activity Number of years participated

Awards/Honors Year

Community involvement:List all community, civic, & church activities.

Activity Number of years participated

Scholastic profile

Must include a high school transcript of grades and have the following section completed by the

appropriate school official:

Applicant ranksin a class of . SAT/ 1600 or 2400 (circle)
or ACT ______

Cumulative grade point average/scale.

School official’s signature

TitleDate

Additional information from student

Any additional information you would like the selection committee to consider:

Goals & aspirations

Describe (type or print) your personal and educational goals including plans for your career and your future. (Confine your response to this page.)

Self-expression

Explain (type or print) why you would be the best candidate to represent HenryCounty as the Lilly Endowment Community Scholar. (Confine your response to this page.)

Recommendations

Please include 3 to 5 completed recommendations with your application. Use the recommendation forms enclosed with this application packet.

Photograph

Include a recent wallet size photograph which will become the property of the Foundation for publicity purposes should you be chosen. Please use paper clip to attach picture, do not staple.

Application checklist

This application for a scholarship becomes complete and valid only when completed in its entirety with all required attachments:

[ ] Student application [ ] Transcript of grades

[ ] Letters of recommendation [ ] Wallet size photograph

Certification

  • In submitting this application I certify the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in termination of any scholarship granted.
  • Misconduct or arrests may result in termination of any scholarship granted.
  • If I receive this scholarship, it is my intent to pursue four years of undergraduate study on a full-time basis leading to a baccalaureate degree at an Indiana college.
  • I understand that the total maximum amount of my scholarship is calculated on the basis of my chosen college’s tuition and required fees beginning with the 2017-18school year.
  • To assist with the processing of my scholarship payments each semester or quarter and to avoid late fees, I will forward to the Henry County Community Foundation immediately upon receipt all invoices for tuition and any eligible fees that may be covered by my scholarship.
  • I will account for the amount of the special allocation spent for required books and required equipment with official receipts and other documentation. I will return to Independent Colleges of Indiana any amount of the special allocation remaining at the end of each school year.
  • I agree to notify Independent Colleges of Indiana of any scholarship awards I may receive for tuition or required fees from a source other than the Lilly Endowment Community Scholarship.
  • I will keep the Henry County Community Foundation apprised annually by June 1st of my enrollment and academic status during college by completing and returning any surveys or forms as may be provided by the community foundation.
  • Upon graduation, I will keep the Henry County Community Foundation apprised annually by June 1st of my education and/or employment status for at least ten yearsaftergraduation, by completing and returning an alumni survey or other forms as may be provided by the community foundation.

Applicant’s signature

Parent/Guardian signature

Date

LILLY ENDOWMENT COMMUNITY SCHOLARSHIP

HENRY COUNTY COMMUNITY FOUNDATION, INC.

RECOMMENDATION FORM

Name of applicant

The above named student is applying for the HenryCounty scholarship. Your recommendation is needed as part of the application process. The student has authorized you to release any information you feel would be helpful in reviewing his/her application. All recommendations are held in strict confidence and the information you provide will not be released to the applicant. Please complete this form and give it to the applicant in a sealed envelope so it can be included in the application packet.

1.What is your relationship with the applicant?

2.How long have you known the applicant?

3.Do you think the applicant has the ability and determination to complete his/her educational objectives and why do you think that?

Please rate the applicant in the following categories:

Very Below

Excellent Good Average Average Poor Unknown

Scholastic achievement

Cooperation

Perseverance

Character

Personality

Work habits

Ability to set realistic goals

Accepts responsibility

If you have additional information that you feel would be helpful to the committee during our deliberation, please feel free to use the reverse side for these comments.

Signature of reference

(Applicant -- Please include 3 to 5 completed recommendations with your application.)