POLISH HERITAGE SOCIETY OF ROCHESTER

P.O. Box 273

WEBSTER, New York 14580

APPLICATION FOR SCHOLARSHIP 2015

A. GENERAL INFORMATION

  1. Name in full (PLEASE TYPE)

LastFirstMiddle

  1. Home address

Number and StreetCity/TownZip

  1. Telephone______
  1. E-MAIL______
  1. Name and address of high school currently attended:
  1. List the college(s) you have applied to:
  1. Describe the course of study you intend to pursue in college and why you made this choice:
  1. Name and telephone number of your school advisor:

B. PERSONAL INFORMATION

1. Date of birth:______2. GENDER:______

  1. Place of birth:______
  2. List the language(s) (other than English) you have competency in and check each line that applies to your ability in that language:

LANGUAGEWRITEUNDERSTANDSPEAK

______

______

  1. List the school honors you have won. Please indicate each year honor was earned:

______

______

______

______

  1. List the school clubs and activities you have participated in along with the years of participation:

______

______

______

______

  1. List the school sports you have participated in along with the years of participation:

______

______

______

  1. List the groups/organization outside of school that you have participated in ANDin what capacity. Please include length of involvement and approximate time commitment per week.:

______

______

______

  1. List your hobbies and special interests AND note any particular achievements and/or recognition:

______

______
______

  1. List the names of other scholarships or financial assistance that you have applied for:

______

______

C. STUDENT FINANCIAL INFORMATION

  1. List any part-time employment during the school year (including place of work, hours worked per week and average weekly wages):

______

______

  1. List any part-time employment during the summer months when not in school (including place of work, hours worked per week and average weekly wages):

______

______

  1. Estimate the amount of financial aid for college you will receive from your family each year while in college:______

4.Estimate the amount of funds you have saved for college: ______

  1. Estimate the yearly cost of tuition, lodging and food at the college of your choice:______

D. FAMILY INFORMATION

1. Father’s name in full:______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

Employed by:______Address:______

2. Mother’s maiden name in full: ______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

Employed by:______Address:______

3. Name of paternal grandfather: ______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

4. Maiden name of paternal grandmother:______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

  1. Name of maternal grandfather:______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

  1. Name of maternal grandmother:______

Birth place:______

CityStateCountry

Living or deceased______Occupation(present or past)______

  1. If your parents are separated, with whom do you live?

______

  1. Which parent is of Polish extraction?

______

  1. How have you been involved in the Polish community (membership in organizations, participation in activities, etc.)?

______

  1. How have your parents been involved in the Polish community (membership in organizations, participation in activities, etc.)?

______

______

  1. MY AUTOBIOGRAPHY

PLEASE TYPE and attach a short autobiography. Include any other information that would help the Scholarship Committee when reviewing your application.

ATTACH A RECENT PHOTOGRAGH OF YOURSELF. PLEASE PAPERCLIP IT TO THE APPLICATION UPON SUBMISSION.

I do so affirm that the above statements are true to the best of my knowledge and I understand that misrepresentation, now or in the future, will automatically disqualify me from scholarship benefits.

Signature:______Date:______

BE SURE THAT YOUR HIGH SCHOOL FORWARDS A COPY OF YOUR ACADEMIC TRANSCRIPT DIRECTLY TO US BY 2-1-15

MAIL OR EMAIL YOUR COMPLETED APPLICATION TO

Scholarship Committee

Polish Heritage Society of Rochester

P.O. Box 273

Webster, New York 14580

Do NOTmail via express mail – simply use regular mail

1