RETURN COMPLETED APPLICATION to MS. CERNOBORI in the C&CC NO LATER THAN FRI., JAN. 20Th

RETURN COMPLETED APPLICATION TO MS. CERNOBORI IN THE C&CC NO LATER THAN FRI., JAN. 20th

Check one or more for consideration for:
□ Need based scholarships * (* the Financial Section [p. 3] + verification of FAFSA EFC required for need scholarships)

□ Non-need based scholarships STUDENT NAME______

Palo alto High School

Community Scholarship Application – 2016-17 Type or print responses in BLACK ink!

Applicant Information

Last Name / First / M.I. / T.A.
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Cell Phone / Date of Birth / Social Security # / DACA#
Are you a citizen of the United States? / YES / NO / If no, are you a legal resident? / YES / NO

Education

Unweighted High School GPA (leave blank>) / (<unweighted GPA based on a 4. 0 Scale)
SAT Scores
(list best from any test) / Critical Reading ______Math ______Writing ______/ ACT Composite Score
Educational Institution you will attend or hope to attend in Fall 2017 (if undecided, indicate whether public or private college):
First Choice (Name) / Second Choice (Name)
* Intended major(s): / Intended minor(s):
Have you been accepted at your first choice? YES NO / If no, when do you expect to be notified? ____/_____/_____
Have you been accepted at your second choice? YES NO / If no, when do you expect to be notified? ____/_____/_____
Will you be attending school full-time? YES NO / Where do you plan to live next year? On-Campus Off-Campus

family information

Are the student’s parents separated or divorced? YES NO / Did either parent graduate from a 4-yr. college? YES NO
List other dependent children and dependent family members. State relationship and college attending, if applicable:
Name and age / Relationship / College

Awards, honors, and achievements

List awards and honors you have received and briefly explain their significance. Complete in full; do NOT attach extra sheets.
Awards/Honors / Level of Recognition (academic department, school, work, regional, state, national, intern’tl) / Grade Level/Date Received

* some scholarships are awarded only for specific majors

School Involvement

List school-related activities in which you have participated. Complete in full; do NOT attach extra sheets.
Activity / Role/Position Held / Dates of Involvement / Hours per month

COMMUNITY SERVICE

List volunteer (unpaid) community service you have performed. Complete in full; do NOT attach extra sheets.
Activity / Role/Position Held / Dates of Involvement / Hours per month

other actvities

List other activities (out-of-school clubs, enrichment programs, sports, unpaid internships, hobbies, family obligations, etc.) in which you have participated. Complete in full; do NOT attach extra sheets.
Activity / Role/Position Held / Dates of Involvement / Hours per month

Employment (PAID work [including babysitting])

Company / Dates of Employment
Job Title / Hours per Month
Responsibilities
Company / Dates of Employment
Job Title / Hours per Month
Responsibilities

FUTURE GOALS AND AMBITIONS

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
The undersigned hereby consent to the release of all information on this application to organizations and others that may wish to provide scholarships.
Student Signature / Date
Parent Signature / Date

FINANCIAL SECTION: REQUIRED FOR NEED-BASED SCHOLARSHIPS, ONLY (CONFIDENTIAL)

It is important to turn in documents on time; don’t wait until you file your tax returns; complete the FAFSA using estimates and amend data once finalized. It may be necessary to submit a copy of your 1040 tax form for certain scholarships. If parents are divorced, responses should reflect only the financial information of the custodial household (parent student lives with 51% or more of the time + stepparent, if custodial parent is remarried).
When did you file the FAFSA? ______Attach a copy of your Student Aid Report with your EFC to this application.
Father’s Name / Employer / Occupation
Father’s 2015 Gross Income Earned $
Mother’s Name / Employer / Occupation
Mother’s 2015 Gross Income Earned $
Father’s/Guardian’s AGI $ / Mother’s/Guardian’s AGI $ / Joint Return AGI (both parents living together or custodial parent + stepparent, if divorced and remarried), if applicable
$
Student’s 2015 Income (e.g. earnings, dividends & interest) $
Student’s Assets (e.g. trusts, individual savings) $
Other Financial Assistance (e.g. employer tuition stipend, other scholarships/grants):
Please describe more fully any financial circumstances that might have bearing on the applicant’s financial need, especially if 2016 looks different than the 2015 data used for FAFSA. As a guideline for qualification of need, we have typically considered families with incomes of less than $125,000 for need-based scholarships.

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
The undersigned hereby consent to the release of all information on this application to organizations and others that may wish to provide scholarships.
Student Signature / Date
Parent Signature / Date