Galesburg-Augusta Scholarship Application

AVANELLE HUTCHINGS POWELL SCHOLARSHIP 9/13

TO BE COMPLETED BY STUDENT AND PARENTS

(Cannot be in the top 10% of your class)

Date:______

DEADLINE: January 15

PERSONAL DATA

Student’s Name______Phone#______

Home Address______

Name of Parents or Guardian______

Home Address______

Are both parents employed? Yes______No______

Father’s Occupation______

Place of Employment______

Mother’s Occupation______

Place of Employment______

Number of children in family______Number younger______

Number in college next school year including this student______

FUTURE PLANS:

I am interested in attending college beginning with the ______semester.

College choice______

Course of study (Major and minor)______

What vocational or professional field do you plan to enter?______

______

Explain why you made this choice______

______

How many years of school will you attend?______

What degree or certification will you earn upon completion?______

FINANCIAL INFORMATION:

How much will it cost you to complete a year of schooling including room and board at the college of your choice? Complete the following according to where you plan to live.

- If you live on campus (dorm) - ______- Yearly Tuition - ______

- If you live in an apartment - ______- Books and Fees - ______

- If you live at home - ______- TOTAL - ______

Have you applied for other scholarships? ______Please list any you have received or expect to receive and the amount.

______

______

How much money did you earn this summer?______

How much did you save for college?______

How much money will you receive from family funds or other sources toward your college education?______

______

(MET, Social Security, separated parent contributions, et cetera)

What percentage of funds needed for the first year of college will be available for the beginning of school this fall?______

______

Please explain:______

Parents and/or students: Please explain any circumstances in the home or family which might create a special need for financial aid:

______

______

______

What is the pre-tax adjusted gross income, combined annual income of both parents with whom you live?

Under $10,000 ______$30,000-35,000 ______$51,000-54,000 ______

$10,000-14,000 ______$35,000-39,000 ______$54,000-57,000 ______

$14,000-17,000 ______$39,000-42,000 ______$57,000-60,000 ______

$17,000-20,000 ______$42.000-45,000 ______$60,000-63,000 ______

$20,000-25,000 ______$45,000-48,000 ______$63,000-66,000 ______

$25,000-30,000 ______$48,000-51,000 ______$66,000-70,000 ______

Over $70,000 ______

How much U.S. Income Tax was paid last year?______

Is the source of income from a business?______

Farm?______

Employed by a company?______Self Employed?______

Is the income: Salary?______Or hourly paid rate?______

ESSAY:

Please write a short essay on your plans for continuing your education beyond high school and your vocational or professional goals after the completion of training. Attach to this application.

Student’s Signature ______Date______

Parent’s Signature ______Date______

*PLEASE NOTE: Student and parent signatures serve as permission to release the attached material to the scholarship selection committees.

Counselor’s Signature______Date______

Please attach a copy of your school transcript and resume.

It is the policy of the Galesburg-Augusta Community Schools that no discriminatory practices based on sex, race, religion, color,

age, national origin, disability, height, weight, or any other status covered by federal, state or local law be allowed in

providing instructional opportunities, programs, services, job placement assistance, employment or in policies governing

student conduct and attendance.

Complaints or inquiries related to discrimination should be forwarded to:

Superintendent of Schools

1076 N. 37th St.

Galesburg, MI 49053

269-484-2000

Dania Bazzi, Superintendent * 1076 N. 37th, Galesburg, MI 49053 * (269) 484-2000 * Fax (269) 484-2001