FORTMORGAN ELS LODGE #1143

SCHOLARSHIP APPLICATION

All Morgan County High School Seniors are eligible to apply for one of the available BPOE Lodge 1143 Scholarships. This application form qualifies the student for each scholarship awarded by the Fort Morgan Elk’s Lodge, but the student may only be awarded one. This application must be returned to the Fort Morgan Elks Lodge on or before Monday, March 11th, 2013 in order to be considered. These scholarships will be considered on the core values of the Benevolent and Protective Order of Elks including: Scholarship, Community Service, Leadership and Financial Need. If you are awarded another scholarship in excess of $2,000 or an aggregate of $2,000 or more, you may not be awarded a Fort Morgan Elks Scholarship. Essays should be typewritten or prepared on a computer. Membership of a parent or grandparent in the Fort Morgan Elks Lodge is not a requirement, but may be considered by the selection committee.

A copy of your ACT or SAT scores and your school transcript MUST be included with your application.

STUDENT INFORMATION

Name:______

Address:______

Phone:______Email Address:______

Date of Birth: ______Last 4 Digits of Social Security Number: ______

Father’s Name:______Occupation: ______

Mother’s Name: ______Occupation: ______

Name of School, Address, Phone Number, and Name of Counselor:

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Anticipated Graduation Date:______

Is parent or grandparent a current member of the Fort Morgan Elk’s Lodge or a member of the Benevolent Protective Order of Elks? Yes____ No ____ Names of parent or grandparent who are members of BPOE Fort Morgan Lodge #1143

Members______

Signature of Student Date______

Describe your college plans.

(State your plans for enrollment in an accredited AmericanCollege or University or TechnicalSchool).

EMPLOYMENT AND COMMUNITY SERVICE

List jobs you have held from January 1st, 2009 through March 1st, 2013.

TYPE OF WORK / NAME OF EMPLOYER / DATE EMPLOYED / HOURS WORKED

List Volunteer work or community service you performed without pay from January 1st, 2009 through March 1st, 2013.

TYPE OF WORK / NAME OF EMPLOYER / DATE EMPLOYED / HOURS WORKED

ACTIVITIES AND ORGANIZATIONS THAT YOU PARCIPATED IN FOR THREE OR MORE YEARS:

Include all scholastic, extracurricular, and civic organizations that you participated in for the last three years during grades 9-12; i.e., Baseball-9, 10, 11; Boy Scouts-10, 11, 12; Sunday School Aid-10, 11, 12

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ACTIVITIES AND ORGANIZATIONS YOU PARTICIPATED IN FOR TWO OR MORE YEARS:

Same example as above

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ACTIVITIES AND ORGANIZATIONS YOU PARTICIPATED IN FOR ONE OR MORE YEARS:

Same example as above

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HONORS AND AWARDS:

Include scholastic, extracurricular, and civic honors during grades 9 through 12. Please state nature of award and grade won; i.e. Girl Scouts-10, Class President-12, Class President-11.

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List and describe leadership positions for School, Community, or Church Organizations that you participated in from January 1, 2009 through March 1, 2013

(Include all scholastic, extracurricular, and civic organizations that you participated in for the last three years during grades 9-12)

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ESSAY

On a separate sheet of paper, answer the following essay question in 500 words or less. The essay must be typed, dated and signed.

If you could have dinner with one individual (current or deceased), who would you chose and why? What issues would you discuss?

FINANCIAL ANALYSIS

In order to assess financial need in the household, please provide the following information:

Gross Family Income: $ ______

Number of Dependents on the 2011 Federal Tax Return: ______

Number of Dependents attending University of College: ______

Please submit a letter describing any extenuating circumstances that should be considered by the selection committee.

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Father/Stepfather SignatureMother/Stepmother Signature

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DateDate