The Central Connecticut Community Women’s Club (formerly The Cromwell Juniors Women’s Club, Inc.) scholarship is awarded to encourage and assist students in furthering their education. Any senior who is a resident of Cromwell, Berlin, Middletown, Middlefield, Newington, Rocky Hill or Wethersfield and plans to continue his or her education after high school graduation is eligible. The committee of the Central Connecticut Community Women’s club will make the selection of the scholarship winner. The scholarship will be awarded on the basis of need, citizenship, scholarship and the quality of the essay.

Please return this 4 pageapplication to your Guidance Counselor by April 1, 2017.

A copy of your transcript, a copy of your SAT/ACT scores and a letter of recommendation from a teacher, coach or guidance counselor must accompany this application.

Name______

Date of Birth______

Home Address______

Telephone Number______

Mother’s Name______

Mother’s Occupation______

Mother’s Place of Employment______

Mother’s Home Address______

Father’s Name______

Father’s Occupation______

Father’s Place of Employment______

Father’s Home Address______

Name Of Guardian (if applicable)______

Guardian’s Address______

Guardian’s Telephone Number______

Siblings:

Name School Age

Page 1

What class or school offices have you held?

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List extracurricular activities.

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What special recognition (honors, awards, etc.) have you received?

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In what organizations outside of school, such as the YMCA, scouts or church have you taken an

active part? Please specify any office held or any special recognition.

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What are your interests or hobbies?

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List the occupations or professions you are considering for your life work.

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Page 2

Please list, in order of preference, the schools or colleges to which you have applied and or have been accepted.

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Have you applied elsewhere for financial aid? If so, where?

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Employment Record

Name of Firm Employed / Position / Dates

Please give the names of two references who have known you for at least two years, other than relatives.

Name______Title______

Address______Phone No.______

Name______Title______

Address______Phone No.______

Page 3

Please write a 150-200 word essay in your own words explaining why this scholarship is important to you. The essay may include, but is not limited to, further information on your special needs, your career goals, interest in continuing your education, extracurricular activities and job experiences.

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I hereby certify that the foregoing data is true according to the best of my knowledge, and I hereby apply for the Central Connecticut Community Women’s Club scholarship to continue my education after high school.

Signature of applicant______

Signature of parent or guardian______

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