Scholarship Application 2017-2018Academic School Year

230 Medical Center Drive

Seaman, OH 45679

937-386-3400

PERSONAL INFORMATION: Date: ______

Full Name: ______Date of Birth:______Sex:______SS#____-___-_____

Address: ______Ph. #: ______

High School attended: ______ACT Score: ______SAT Score: ______

HS GPA: ______Class Standing:_____/_____ List any OGT “Advanced” score subjects:______

State/National /Scholastic Awards: ______

AP classes:__Yes __No Number of classes:_____ , PSEO classes:__Yes __No Number of classes:_____ College:______

College/University applied to: ______Major/Minor: ______

______

Have you been accepted? __Yes __No Have you been accepted in your selected program? __Yes __No

College Education Level(as of July 2016): __Freshman __Sophomore

__Junior __Senior __Post Grad 1 2 3 4

Credit Hours completed: _____ College GPA: ______

Will you be a full time student during the 2017-2018school year? __Yes __No

Marital Status: __Single __Married __Divorced/Separated

2A. Did or will you live with your parents/guardian for more than six months? Last year: _Yes _No This year: _ Yes _No

2B. Did or will your parents/guardian claim you as a U.S. income exemption? Last year: _ Yes _No This year: _ Yes _No

2C. Did or will you get more than $750 worth of support from your parents/guardian? Last year: _ Yes _No This year: _ Yes _No

How many people live in your household? ____ How many people listed in the household will be in college during the coming year? ____

From the latest federal income tax return, indicate the range of taxable income

(answer both Yours and Parents/Guardian if marked yes on 2A, 2B or 2C):

Yours:__ Less than $14,999 __ $15,000-$29,999 __ $30,000-$44,999 __ $45,000-$74,999 __ $75,000-$99,999 __ $100,000 + __ didn’t have to file

Your Parents/Guardians: __ Less than $14,999 __ $15,000-$29,999 __ $30,000-$44,999 __ $45,000-$74,999 __ $75,000-$99,999 __ $100,000 +

SCHOLARSHIPS APPLIED FOR:

__ Morrill (OSU) __ Other: ______

__ Land Grant__ Other: ______

__C103__ Other: ______

__ Other: ______College/University Awards:

__ Johnson Memorial__ Other: ______

__Pixley Memorial (*Thru Scioto Co Area Foundation)______

MORE ABOUT YOU:

List your Volunteer Work and/or Community Activities during the past four years (Ex: Boy/Girl Scouts, 4-H, Clubs, Church, etc.): ACRMC Volunteen:__Yes __No Explorer Post 911 Volunteer:__Yes __No

Activity Approx DatesHrs per WeekDescribe your participation

______

List your extracurricular school activities (ex: sports, drama, clubs, student government, etc.):

______

List your interests and other activities:

______

List work experience in the last four years:

PositionEmployerDatesHours per week

______

List three references (not relatives) (ex: school principal, school counselor, teacher, pastor, etc.) and attach letters of recommendation from these individuals:

NameAddressOccupation

1.______2.______

3.______

Describe your short-term academic and life goals:

______

What would you like to achieve during your lifetime? Describe your long-termacademic and life goals:

______

Are there any extenuating circumstance or financial hardships that you would like the scholarship committee to know when considering your application?

______

Tell us a little about yourself:

______

Please list any grants, scholarships or work/study awards you have or will receive for the current or upcoming school year (failure to list any known scholarships will result in an automatic disqualification):

NameAmountSchool year

______$______2017-2018 __2018-2019

DISCLAIMOR

I hereby certify that the information on this form is true and correct to the best of my knowledge and belief.

The under signed authorizes the regents of ACRMC to permit the use and display of any submitted photos and/or photos taken at the scholarship interview in any publication, multimedia production, display, advertisement or world-wide web publication. The undersigned agree that the regents of ACRMC may use name, likeness or biographical information supplied by the undersigned. The undersigned release and forever discharges the regents of ACRMC, its agents, officers and employees from any and all claims and demands arising out of or in connection with the use of said photographs/images, including but not limited to, any claims for invasion of privacy of defamation.

Applicant’s Signature: ______Date ______

Parent/Guardian (if under 18 yrs of age): ______

G drive: AdminAsst/ScholarshipInformation-forms/ScholarshipApplicationrev. 7/13, 1/14, 3/15, 1/16, 2/17, 2/18

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