Wichita Hispanic Chamber of Commerce

SECTION 1: PERSONAL INFORMATION

Last Name, First Name, MI
Address
City, State, Zip Code
1. / Date of Birth
2. /
Male or Female
3. / Home Phone Number
4. / Cell Phone Number
5. /
Email Address
6. /
Are you a U. S. citizen/or legal permanent resident?
(Some scholarships require U.S. citizenship.) /
[ ] Yes [ ] No
7. / Ethnic/Cultural Background?
Mark all that apply. / [ ] Mexican
[ ] Puerto Rican
[ ] Cuban
[ ] Dominican
[ ] South American
[ ] Central American
[ ] Other

SECTION 2: HIGH SCHOOLINFORMATION

9. / Name of current high school
10. / High school counselor name
11. / High school counselor’s email address
12. / Cumulative GPA (Non Weighted)
13. / ACT or SAT Composite Score
Last Name, First Name, MI

14. ACADEMIC RECORD

List the names of the honors, and advanced placement classes, the letter grade,and the academic year classes were completed.

NAME OF CLASS / GRADE / GRADE
Honors English I / A / 11th-12thGR
a.
b.
c.
d.
15. / If enrolled in an academic/career program, name the program.
16. / Total number of college credits earned/enrolled.

17. ACADEMIC HONORS

List the up to4academic and leadership honors, name of institution awarding the honors, and academic year awarded.

NAME OF ACADEMIC & LEADERSHIP HONOR / INSTITUTION AWARDING HONOR / GRADE
Kansas Honors Society / University of Kansas / 11th-12thGR
a.
b.
c.
d.

18. EXTRACURICULAR ACTIVITIES HONORS

List up to 4extracurricular activities, highest positions held and academic year of activities.

NAME OF EXTRACURRICULAR ACTIVITY / HIGHEST POSITION HELD / GRADE
Track / Captain / 11th-12th GR
a.
b.
c.
d.

19. COMMUNITY SERVICE

List up to4organizations where you performed community services, the names of the activity, and the academic year of the activities.

NAME OF ORGANIZATION / NAME OF ACTIVITY / GRADE
Salvation Army / Operation Holiday / 11th-12th GR
a.
b.
c.
d.
Last Name, First Name, MI

SECTION 3: EDUCATIONAL INSTITUTION INFORMATION

20. /
Intended Major
21. /
List the names of twoeducational institutions you prefer to attend according to your preference. / 1st choice
2nd choice

SECTION 4: FINANCIAL INFORMATION

22. /
Do you qualify for free or reduced lunch? / [ ] Yes [ ] No

A. EMPLOYMENT INFORMATION

23. / Are you employed? If yes, answer questions 24 and 25. /
[ ] Yes [ ] No
24. / How many hours per week do you work?
25. /
Place of employment.

B. FINANCIAL ASSISTANCE INFORMATION

List all sources of financial assistance and scholarships you will receive for the 2015-2016academic school year:

26. / NAME OF SCHOLARSHIP / TUITION, HOUSING, BOOKS, OTHER / AMOUNT / PER SEMESTER
Kansas State University / Books / $500 / $250/2 Semesters
a.
b.
c.
d.
27. /
Besides yourself, how many in your household will be attending college in the 2015-2016academic years?
28. /
Are you the first person in your immediate family to attend a college or university? / [ ] Yes [ ] No
Last Name, First Name, MI

C: PARENT AND GUARDIAN INFORMATION

29. /
What is your family’s estimated2014annualgross income?
30. / Number of family members living in the household supported by the reported income listed above.
Household information—Indicate below who you live with. (Check the appropriate column.)
Independent—live on my own
Live with both parents
Single parent household
Father’s Information
Last Name, First Name
Address
City, State, Zip Code
Phone Number
Mother’s Information
Last Name, First Name
Address
City, State, Zip Code
Phone Number

SECTION 5: LETTERS OF RECOMMENDATIONS

The Kansas Hispanic Scholarship Program requires two letters of recommendation.
Letters should be submitted from instructors and counselors in regards to your academic and leadership ability and/or employers and supervisorsin regards to your community and work experience.
Please mail letters of recommendations in the same large envelope with the other documents. Your school officials might prefer to send them in sealed letters which you can include in the large envelope.

SECTION 6: ESSAY
Select one option from below and compose a one page double-space essay using 1” margins. Type your name, high school & date on the right hand corner of the essay.

Option 1: Tell us about an experience that defines who you are.

Option 2: Recount an incident or time when you experienced failure. How did it affect you, and what lessons did you learn.

SECTION 7: OFFICIAL TRANSCRIPT

An official transcript is required. Please contact the appropriate school administration office to obtain the transcript.

Last Name, First Name, MI

SECTION8: PERSONAL STATEMENTS

Each scholarship applicantis REQUIRED to answer the following personal statements in the spaces provided.

Click in the spaces provided. Do not exceed one page.

a. / What are your academic and educational goals, and why?
b. / How have you been a positive role model in your community?
c. / What school or community work are you most proud of?
d. / What financial obligations & extenuating circumstances necessitate a need for a scholarship from the Kansas Hispanic Scholarship Program?
e. / What additional information would you like for us to know about yourself when considering you as a scholarship recipient?
Last Name, First Name, MI

SECTION9: CERTIFICATION AND AUTHORIZATION

All of the information that I have provided in this application and in the enclosed documents is accurate and complete to the best of my knowledge. I understand and acknowledge that providing false or misleading information may lead to the rescinding of my award.

I authorize the Kansas Hispanic Education & Development Foundation (KHEDF) to verify any of the information contained herein—either prior to, or after a scholarship is awarded.

I hereby authorize the Kansas Hispanic Education & Development Foundationto use any information contained in this application for the purpose of promotion of the Kansas Hispanic Scholarship Program.

Applicant signature Date

Parent or

Guardian’s signature Date

(Parent or Guardian’s signature is required if applicant is under 18 years of age.)

SECTION 10: RELEASE OF RECORDS

I hereby authorizepermission to release my secondary school records and other requested information for consideration in
the Kansas Hispanic Scholarship Program.

Applicant signature Date

Parent or

Guardian’s signatureDate

(Parent or Guardian’s signature is required if applicant is under 18 years of age.)

Section 11: Application Checklist
Your application packet must contain the following:

Completed signed application form (Sections 9 & 10)
2 Letters of recommendation (Section 5)
Essay (Section 6)
Official transcript (Section 7)
Personal Statements (Section 8)

SECTION 12: MAIL APPLICATION

Send your completed application and all required documents, postmarked by February 1, 2015 to:

KHEDF

PO BOX 4248
Wichita, KS 67204

Award Letters

Award letters will be mailed prior to May 1st. and will include the name of the scholarship and the amount of the scholarship. The letters will also include the name of the donorand the address of the donor as well as anyadditional donor requirements.
For additional questions, please email Irma Luna at .