Scholarship Application for Health Care Professions and/or Single Working Parents

Personal Information Date: ______

Name: ______

Address: ______City______Zip______

County______You must be a resident of Wake, Durham or Orange County to receive aid.

U.S. Citizen: YES _____ NO _____ Permanent Resident: YES _____ NO_____

Please submit proof of permanent resident status if you are not a U. S. citizen.

Home Phone: ______Cell Phone: ______

Email: ______@______

List ages of dependent children in household: ______none_____

Are you a single working parent? YES _____ NO_____

Are you applying for assistance to pursue a health care career? YES _____ NO

High School/GED: ______Graduation Date: ______GPA: ______

College(s): ______Dates Attended: ______GPA: ______

______

______

If you are currently enrolled in college, please give your student ID number______

How many classes do you need to complete your program? ______

What is your anticipated graduation date? ______

Financial information:

Total 2016 Household Income: ______Applicant’s Income ______

List ages of dependent children in household: ______none_____

This is a needs based scholarship. Provide a description of your financial need:

Educational Plans

Please state the name of the college, university or technical school you are applying to, have been accepted to or currently attending:

1.

2.

3.

When do you plan to start/continue your education? Summer 2017 _____ Fall 2017 _____

What field of study do you plan to pursue and why?

Employment History

Name/Place of EmploymentPosition(s) HeldDates of Employment

1.

2.

3.

4.

5.

Extracurricular Activities for the past 5 years

List community service, volunteer or additional activities in which you have participated:

ActivityHoursDatesPosition Held

List post high school or professional awards or honors you have received:

Personal Statement (optional): Is there anything else you would like the scholarship selection committee to know about you or your family?

The following must be attached to this form:
  • Verification of High School Graduation, including transcript and GPA, or GED
  • Current College/University transcript and GPA, if applicable
  • Complete copy of FAFSA/SAR form showing income, number of dependents
  • Proof of permanent resident status if applicable.
  • Essay: 300 to 500 words on the following topic:Describe a post high school experience that has had a strong impact on your educational objectives or goals.
• Two letters of references:
- One reference must be from an employer or professional associate
- One reference from someone outside your family who knows you well
Incomplete or Late Applications Will Be Disqualified
This application must be postmarked by March 1, 2017* and sent to:
AssistanceLeagueof theTriangle Area
Scholarship Committee
P. O. Box 98477
Raleigh, NC 27624
Scholarship Phone (919) 438-1682
A - Z Thrift Shop Phone (919) 875-8901
*If you are mailing on March 1go into the post office and have the clerk hand cancel your envelope. If you drop it in a box, it will be postmarked on the March 2 and will be disqualified.