GLADYS L. JOHNSON SCHOLARSHIP TRUST

ChisagoLakeLutheranChurch

P. O. Box 175

Center City, Minnesota55012

FOR: 1. Residents of Minnesota and WisconsinHigh Schools

2. Students of Protestant Faith.

RULES:1. Eligibility based on financial need, academic and vocational achievement, service to school and community.

2. Type of school may be any private college, public college, university, or vocational institute.

3. Scholarship must be used within 12 months of award.

4. Funds will be paid directly to the institution by Gladys L. Johnson

Scholarship Trust to defray living cost, tuition and supplies. The receiving institution must account for the use of the funds.

5. Scholarship grants in any one school year are for amounts of up to $1,000. Each application is good for one year only.

6. Selection is made by the Board of Directors of the Gladys L. Johnson

Scholarship Trust, P. O. Box 175, Center City, Minnesota55012.

7. Applicant must submit a copy of the most recent high school transcript with the application.

8. The applicant must complete the financial section of this application

for a Gladys Johnson Scholarship.

  1. Applications must be delivered to student’s high school career counselor’s office no later than April 18th, 2018 or mailed to the Church office no later than April 18th, 2018 to the address above.

10. AWARDS: Scholarship recipients will be notified in May.

GLADYS L. JOHNSON SCHOLARSHIP TRUST
BOX 175
CENTER CITY, MN 55012

Name______

Last First Middle

Address______

StreetCityStateZip

Home Phone Number______Graduation Date______

HIGH SCHOOL INFORMATION

High School______City______

PSEO: College______City______

Rank______Cum. GPA______

ACT______SAT______

Counselor Signature______

*You MUST attach an official copy of your transcript*

COLLEGE INFORMATION

1ST Choice______City______

Applied: Y / N Accepted: Y / N

2nd Choice ______City______

Applied: Y / N Accepted: Y / N

Major:______Minor:______

Scholarship Application MUST be returned

to counselor by: April 18th, 2018 or mail to the Church office at the address listed above by April 18th, 2018.

ACTIVITIES & AWARDS

Please list all activities and awards you have received. If you need more space, attach an additional page.

Activity / Years Participated / Awards, Honors, etc.
COMMUNITY SERVICE / VOLUNTEERING

Please list all community service or volunteering activities you have been involved with. If you need more space, attach an additional page.

Service
/ Organization / Years Participated
PERSONAL REFERENCES

A personal reference form is enclosed. You may duplicate this for additional references (up to 3) or submit a letter of reference. Please have either a school staff member or pastor complete the attached form and return it to your High School.

References:

1.______Relationship______

2.______Relationship______

3. ______Relationship______

COLLEGE FINANCIAL INFORMATION

This section must be completed.

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RESOURCES

Scholarships:

______$______

______$______

______$ ______

Parents: $ ______

Applicants Savings: $ ______

Summer Earnings : $ ______

Loans: $ ______

Other Assets: $______

TOTAL: $______

EXPENSES

Fees & Tuition: $______

Room & Board: $______

Books & Supplies: $______

Personal Expenses: $______

Transportation: $______

TOTAL: $______

Total Expenses $______

Subtract--

Total Resources $______

Additional

Resources Needed: $______

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PARENT FINANCIAL SECTION

Father, Step-Father, Guardian

Name:______Age:______

Home Address:______

Occupation:______Title:______

Mother, Step-Mother, Guardian

Name:______Age:______

Home Address:______

Occupation:______Title:______

Parents Annual Adjusted Gross income from 2017IRS Form 1040 or 1040A

Father______Mother______Total______

Parent/s Savings

Father______Mother______Total______

How many dependent children, including the applicant, will you claim as Federal income tax exemptions?

Last Year______This Year______

How many dependent children entered above will be attending post-secondary schools next year?______

I certify that the above information is accurate and true.

Student Signature______Date______

Parent Signature______Date______

Parent Signature______Date______

PERSONAL STATEMENT

Use the space provided below to write how this scholarship would benefit your educational goals.

Name:______Date:______

Signature:______

Student______

______

Street AddressCityStateZip

is in the process of making application for a Gladys L. Johnson Scholarship Trust award. The applicant has been asked to submit it to either a school staff member (teacher, counselor, administrator, etc.) or pastor. To help the Scholarship Committee better evaluate this applicant, please answer the following questions, sign, date the form at the bottom, and return to Chisago Lake Lutheran Church. If you have any questions or desire further information, please contact (651) 257-6300.

1. How long have you known the applicant?

2. What is your relationship to the applicant?

3. What is your estimate of the applicant’s potential for post secondary achievement?

4. List any awards, achievements or activities the applicant has participated in or received.

5. List any additional information you feel is pertinent to the applicant.

I certify that the above information is accurate and true.

______

Name and Title

______

Address

______

Phone Date

PLEASE RETURN the reference form to Chisago Lake Lutheran Church, P.O. Box 175, Center City, MN 55012 by April 18th, 2018

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