Jay-Sea Scholarship

Application

This scholarship was established in 2014by Danielle Moser in honor of her parents Greg and Marianne Moser who passed away in 2003.

Scholarship candidates should:

  1. Be a graduating high school student from Jay County High School, Jay County, Indiana orfrom a high school in King County, Washington
  2. Have had at least one parent pass away

To the applicants regarding this scholarship application:

We ask that you be as accurate as possible knowing that any false or misleading information may disqualify you for consideration. Please be assured that all information will be treated with the strictest confidence.

All scholarship awards received must be used to cover the costs of tuition, required fees and books only. Any misuse of funds will result in the repayment of all scholarship awards.

SCHOLARSHIP SELECTION PROCESS:

This is a donor advised scholarship held by The Portland Foundation. The donor will work with the Portland Foundation Scholarship Committee with selecting the recipient. The Portland Foundation Scholarship Committee is composed of members of the Portland Foundation Board of Trustees. The committee reviews all applications turned in by the deadline.

To be considered for this scholarship, please complete the attached application and return it to The Portland Foundation, 112 East Main Street, Portland, IN 47371, no later than:

February 25, 2016

JAY-SEA SCHOLARSHIP

APPLICATION

(Please type or print in ink)

1. STUDENT IDENTIFICATION INFORMATION:

Name______

(Last)(First)(MI)

Permanent Home Address______

(Number, Street and Apartment Number)

______

(City)(State)(Zip Code)

Telephone Number______

Date of Birth______

Mark One: _____ I am single _____ I am married _____ I am legally separated

2. HOUSEHOLD INFORMATION: (Information in this section should reflect information only about where the student is living; that is, custodial parent).

With whom is the student living: Single parent, parent and step-parent, legal guardian etc. Please indicate name and relationship to student.

______

Number of family members currently living in your household: ______

List names of brothers (B), sisters (S), step-brothers (SB), step-sisters (SS) currently living with you in your home. Include name and relationship. If there is an adult child living at home but who works outside of the home please indicate this by putting "WO" by their name.

______

______

______

Number of college students in the household next school year: _____

NameYear in schoolSchool Attending

______

______

______

______

3. FINANCIAL NEED

Please provide explanation of financial need of assistance for education:

______

4. STUDENT ACTIVITY

Name of university, college or technical school you plan to attend:

______

SchoolLocation

Have you received official notification of acceptance? ______

If you have been accepted by a college or university, have you been notified that you will receive any financial aid from that institution which will be applied toward your college expenses? ______If yes, please indicate amount ______

What is your intended major at this school? ______

This is a _____ 1 year _____ 2 year _____ 3 year _____ 4 year or longer program of study.

List all school and community activities in which you have participated and any honors which you might have received.

______

______

During your high school years did you work during vacations, outside of school hours or during summers? ______

If yes, during what years of school did you work? Please include work on family farm.

Dates duringNumber of Employer Dates duringNumber ofEmployer

school yearhours workedsummerhours worked

per weekper week

Fr.______

______

______

So.______

______

______

Jr.______

______

______

Sr.______

______

______

Will it be necessary for you to work while pursuing a higher education? _____

If yes, approximately how many hours do you anticipate working per week? ______

5. WRITTEN ESSAY

In no more than 500 words please submit a typewritten essay on a separate sheet that explains how the loss of your parent/parents has influenced your development and future goals.

In submitting this application I certify that the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in termination of any scholarship granted.

Applicant’s signature ______Date ______

Parent/Guardian signature ______Date______

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