Doris A. Ackerman and Family Scholarship Application Select any for which you are applying.

Mabel L. Kuebler Nursing Endowment Application

Mildred E. Schwinghammer Nursing Scholarship Application

St. Joseph Hospital Auxiliary Scholarship Application(Southridge graduates only)

Kathleen M. Tempel Nursing Scholarship Application

Section A

Name:______Age: ______

Last First Middle Initial

Personal Information (complete as applicable):

Resides in

Household Deceased

Father/Guardian’s Name:______( )( )

Mother/Guardian’s Name:______( )( )

Spouse’s Name:______( )( )

Home Address: ______

Street AddressCity State Zip

Home Phone #: ______Cell Phone #: ______

Academic Information:

High School Attended: ______Year of Graduation: ______

Grade Point Average: ______Class Rank: ______out of: ______

Highest SAT Critical Reasoning: ______Highest SAT Math: ______Highest SAT Writing: ______

Composite ACT Score: ______

College You Plan to Attend: ______

Intended College Major: ______Years Required to Complete This Degree: ______

Have you received an official letter of acceptance at this time? Yes: _____No: _____

Household Information:

Father’s/Spouse’s Occupation: ______Employer: ______

Mother’s Occupation: ______Employer: ______

Number of brothers and sisters residing in household:Older: ______Younger: ______

Please list any brothers and sisters in a post high-school educational program and list the school name(s): ______

______

______

Section B

Financial Information:

1)Federal Adjusted Gross Income [AGI] (as listed on line # 37 of yourmost recent Federal Form 1040),Taxable Income (as listed on line # 43 of yourlast year’s tax return):

AGI: ______Taxable Income:______

Exemptions Claimed (as listed on line # 6d of yourFederal Form 1040): Exemptions: ______

Federal Adjusted Gross Income [AGI] (as listed on line # 37 of your parents’most recent Federal Form 1040),

& Taxable Income (as listed on line # 43 of your parents’last year’s tax return):

AGI: ______Taxable Income:______

Exemptions Claimed (as listed on line # 6d of your parents’Federal Form 1040):Exemptions: ______

Other Aid/Income not included onyour or your parent’s tax return (circle appropriate item):

Tips, Welfare benefits, Social Security, Non-taxable pensions, Child Support, Workers Compensation,

Other (List):

______$

2) Applicant’s estimated financial resources for the next academic year.

a)Cash Resources:

Projected summer income:$ ______

Projected earnings during the next school year:$ ______

Current value of applicant’s personal savings and checking accounts: $ ______

Financial contributions from parents (if applicable, i.e., if applicant is a minor): $ ______

b)Please list all scholarships and amounts that you have already received or will receive.

Scholarship: ______Amount: $ ______

Scholarship: ______Amount: $ ______

Scholarship: ______Amount: $ ______

c) Are you presently employed? ______Employer ______

Do you have any extraordinary family expense? Please explain: ______

______

Describe your other work activities (such as family farm, helping at home, clubs, volunteering, etc.)

______

______

Section C

1)Applicant’s estimated expenses for the next academic year.

a)Expenses

Tuition & Fees$ ______

Room and Board $ ______

b) Other Specialized Fees$ ______Explain ______

Section D

Individual Student Profile:

Name or type of Diploma/Degree received (or to be received): ______

High School/College activities in which you have participated: (clubs, extracurricular, sports, etc.):

Years Years

a)______e)______

b)______f)______

c)______g)______

d)______h)______

Awards, Honors, or Letters you have received:

a) ______e)______

b)______f)______

c) ______g)______

d)______h)______

Leadership positions held: (includes academic, athletic, community, and/or workplace):

a) ______e) ______

b) ______f) ______

c) ______g) ______

d) ______h) ______

Services you have rendered to your school and/or community:

a) ______e) ______

b) ______f) ______

Community organizations to which you belong:

a)______b)______c) ______

Community leadership roles: ______

Community honors received: ______

Exceptional or original talents you feel you have demonstrated in the areas of art, music, science, literature, mathematics, or industrial arts:

______

______

Principal strengths as a person: ______

______

Principal academic strengths: ______

______

Do you plan to return to Dubois County and work after you receive your degree? YES NO

Attachments:

  1. Include a copy of your transcript showing information for three and one-half years of high school and/or transcripts of your past four college semesters (freshman & sophomore years if applicable).
  1. Three reference letters: one personal (from a minister, friend, scout leader, etc.); one from a current or past employer(from a boss or supervisor, etc.) or one demonstrating Community Involvement (from a civic club, local organization, etc.), and one from a teacher or administrator supporting your academic and personal record.
  1. If already accepted into a nursing program, please provide a letter of verification from the school.
  1. A statement of 250 words or less as to why you are preparing for your vocation and why you are applying for this scholarship.Please do not use the phrase,“…because I have always wanted to help people…” (or a related phrase).

I HEREBY TESTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

______

Applicant’s signatureParent or Guardian signature (if applicant is a minor)

Scholarship Revised 2016