Scholarship & Recogniton Programs

/ Bucks County (PA) Chapter of The Links, Incorporated
Scholarship Application for the 2016-17 Academic Year
This form is designed to collect information about your background, interests, academics, and career plans. Your answers to these questions will be used only in connection with your application to the Buck County Chapter of The Links, Inc. scholarship program and will be reviewed only by the Scholarship Committee. The completeness, neatness, and legibility of your replies will make the review of your credentials easier. Please TYPE or PRINT LEGIBLY using BLACK INK. You may add additional pages or print responses on your computer and paste the responses into the appropriate section. This application is also available at
DEADLINE FOR SUBMISSION IS FEBRUARY 29, 2016

Institution Planning to Attend (check one):

4 Year College Degree

2-Year Associate Degree

Vocational/Technical

ZAPPLICANTZ

Legal Name
Last / First / MI
Permanent Home Address
Number and Street
Male Female
Ethnic Background:______
City / State / Zip Code
Country (if different than United States) / E-Mail Address
Home Telephone Number / Date of Birth
- / - / / / /
CELL PHONE NUMBER / Month / Day / Year
- / - / Are you a permanent resident of Bucks County Pennsylvania? Yes No
If no, please explain:
ZEDUCATIONZ
Give the name and location of your high school.
School Name
City / State / Zip Code

Are you currently a high school senior? Yes No

Enter your HIGH SCHOOL graduation date.
What college do you attend or plan to attend?
What is your planned course of study?
Other than the high school named above, list all schools that you attended in the last three years. List the school you attended most recently first.

Name of School

/ Location (City and State) / Dates of Attendance
List special courses or programs you have taken during the last three years. List the most recent course or program first (AP, Honors, Dual Enrollment, International Baccalaureate, data processing, electronics, etc.).
Course or Program / Name of School / Dates of Attendance

Page 2

ZSCHOOL AND COMMUNITY ACTIVITIESZ

List activities in which you have participated during the last three years. (School clubs, student government, publications, varsity or club sports, theater arts, Beta Club, Scouting, VICA, 4-H, etc.).

Activity / Dates of Participation / Office/Position Held / Awards or Honors

List community agencies or organizations in which you have participated without pay during the last three years. (Church, hospital volunteer, cultural activities, outreach programs, etc.).

Name of Agency or Organization / Kind of Activity / Dates of Participation / Hours Per Week

List jobs (including summer employment) you have held in the last three years.

Job or Type of Work / Employer / Summer / School Year / Dates of Employment / Hours per Week

From the courses, activities, internships, and work experience, which one did you find most rewarding or personally satisfying?

Explain why.

Page 3

ZFAMILY INFORMATIONZ

Enter complete information about your family below.

Father/Male Guardian / Mother/Female Guardian
Name
Occupation/Title
Employer’s Name
Parents’ marital status: / Married / Separated / Divorced / Widowed
Brother(s): / Number / Age(s) / Sister(s): / Number / Age(s)
Enter the name(s) of the parent(s) or guardian you live with, if different from above.

How has a family member or family experience been influential in your life?

ZFUTURE PLANSZ
Where do you expect to be 10 years from now, and what do you anticipate you will be doing?

ANTICIPATED FINANCIAL ASSISTANCEZPage 4

Please list below all sources and amounts of assistance that you anticipate will be used to cover your college expenses. Indicate whether you have applied for this assistance and whether it has been definitely awarded. Please indicate the level of your family income.

Expected Contribution to 2016-17 AYCollege ExpensesFamily Income

Family$______(Please check one box.)

Personal Earnings$______

High School Award$______ Applied  AwardedUnder $25,000

Church$______ Applied  Awarded$25,000 - $49,999

Social Security $______$50,000 - $74,999

(If a parent is deceased, indicate the amount you currently receive.)$75,000 - $99,999

Senatorial$______ Applied  Awarded$100,000 - $124,999

PHEAA$______ Applied  Awarded$125,000 - $149,999

Other, please indicate sources:  $150,000 or more

______$______ Applied  Awarded

Personal RECOMMENDATIONZ
A personal recommendation is also requested. This recommendation must address your academic work, school and/or community activities, and potential for success. You should ask an adult who is familiar with your academic work and activities to submit a letter for the committee’s consideration directly to the address below.
ZAUTHORIZATION/CERTIFICATIONZ
Please review your responses, sign your name below, and give this form to a school official for completion. The signatures below will authorize your school to release the information requested and certify that all information entered on this form is accurate and true.
NOTE: IT IS YOUR RESPONSIBILITY TO ENSURE THAT YOUR SCHOOL RELEASES THE REQUESTED INFORMATION BY THE DEADLINE OF FEBRUARY29, 2016.
Student’s Name (Please Print) ______
Student’s Signature ______Date______
Parent/Guardian’s Name (Please Print) ______
Parent/Guardian’s Signature ______Date ______

ZSCHOOL INFORMATIONZ

NOTE FOR SCHOOL OFFICIAL: Please provide the information requested, sign the form, and attach an official transcript of the student’s grades that includes grades from the first term for this academic year and the remaining senior year courses being taken. If a school profile is available, please include one with this form. Thank you for taking the time to assist with this scholarship application.

Student’s Class Rank / Class Size / Student’s GPA / •
TEST SCORES / ACT / Test Date:
/ SAT I / Test Date:
Composite Score: /
/ Verbal: /
/ Math: /

Please rate the level of difficulty of the courses this student has attempted:

Most Difficult / Above Average / Average / Below Average
School RECOMMENDATIONZA Written recommendation is required for this student.
Please type or print on school letterhead and enclose with this form. Please address the student’s academic work, school and community activities, and potential for success. Please describe the special qualities and abilities of this student. Does the student have any special talents or skills, strengths or weaknesses? Are there special circumstances or obstacles that the student has had to overcome?
Please make certain to include the transcript.
Mail all scholarship materials byFEBRUARY29, 2016 to:
Bucks County (PA) Chapter of the Links, Incorporated
Scholarship Committee
c/o Constance White
P. O. Box 1072
Doylestown, PA 18901
385-645-4657

Name & Title of School Official
Signature of School Official
Phone Number / Date