Etmc-quitman High School Auxiliary Scholarship Application



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2015-16 ETMC-Quitman High School Auxiliary Scholarship Application

* Illegible applications or applications not containing all of the required information and documentation will not be considered.


Section 1 – Personal Data
Name: ______________________________________________________ Sex: Male Female (circle)

Date of Birth: ___________________________ Primary Language Spoken at home: _________________________

Do you reside with your parent(s)? Yes No (circle)

Permanent Address: ___________________________________________________________________________

City: ___________________________________________________________ Zip Code: ___________________

Mailing Address: ______________________________________________________________________________

City: ___________________________________________________________ Zip Code: ___________________

Home Phone: _____________________________________Cell Phone: __________________________________

Email Address: ________________________________________________________________________________
Section 2 – Financial Information

Are you totally dependent on your parents/guardian? Yes No (circle)

If no, what amount/type of support do you receive? _________________________________________________

Father’s Name: _____________________________________ Occupation: ____________________________

Mother’s Name: _____________________________________ Occupation: ____________________________

Number of other dependent(s) of your parents/guardian: ________________



Name Age Relationship School Attending

_______________________ __________ __________________ ________________________________

_______________________ __________ __________________ ________________________________

_______________________ __________ __________________ ________________________________

_______________________ __________ __________________ ________________________________
Estimated cost of expenses per YEAR for tuition, books, room & board, and school related fees:

$________ tuition/ $________ books/ $________ room & board/ $________ fees/ $__________total cost

What is the length of time estimated to complete your program of study? _________ months / years (circle one)
Starting with the most current, please list paid jobs and internships you have held during the past three years.

Specific nature of work Employer School Yr. /Summer Dates Hours per wk.

_______________________ __________________ __________ ___________

_______________________ __________________ __________ ___________

_______________________ __________________ __________ ___________

_______________________ __________________ __________ ___________

Are you employed now? Yes / No (circle one) What is your monthly salary? $ _________________



Section 3 – For Current Seniors or Jr. Volunteer Applicants Only

High School NOW Attending: ___________________________________________________________________

Date of High School Graduation: ____________________________ Class Rank: ________out of _________

Are you graduating with college credits? Yes No (circle) If so, how many? __________________

High School cumulative GPA (>3.0): _____________________ SAT: _____________ ACT: _______________

College you would like to attend: _________________________________________ Accepted? __________


Section 4 – Other Scholarships/Grants/Loans for ALL Applicants

Please list all other scholarships, grants and/or loans you have applied for or received for the upcoming school year.



Name Applied or Received Notification Date Amount $$

1. ___________________________________ _______________________ _______________ __________

2. ___________________________________ _______________________ _______________ __________

3. ___________________________________ _______________________ _______________ __________

4. ___________________________________ _______________________ _______________ __________

5. ___________________________________ _______________________ _______________ __________


Section 5 – Honors and Awards for ALL Applicants

In order of importance to you, list up to five recognitions, honors or awards you have received during the last four years. Please be specific in recording the year of the award and who gave the award.

Year(s) Recognition, Honor or Award
_______ _____________________________________________________________________________

_______ _____________________________________________________________________________

_______ _____________________________________________________________________________

_______ _____________________________________________________________________________

_______ _____________________________________________________________________________

Section 6 – Activities for High School

On the following pages please list your principal extracurricular, community and volunteer activities in addition to your unpaid internships over the last four years, beginning with the current school year. Do not include any hours spent in classroom time. For example, do not include band class hours but do include band practice hours spent before or after regular school hours.

To allow us to focus on the highlights of your career, please list in this section only the ten activities you have spent

the most time on during this four year period. If you do not have ten, that is okay. This section must be filled out even if you choose to attach a resume’ showing all of your activities. If you do not have a record of exact hours spent, you may estimate (there are approximately 36 weeks in a school year and 12 weeks in a summer; for example, use this formula: Hours per wk. X Total Wks. X Total Yrs. = Total Hours ).

.

Year(s) Total Hours Spent Term

School Yr. Summer

_______ _______ _______ _______



  1. Activity __________________________________________________________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________

Year(s) Total Hours Spent Term

School Yr. Summer

_______ _______ _______ _______



  1. Activity _________________________________________________ _________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity __________________________________________________________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity __________________________________________________________________________________

Leadership Role (if any) _____________________________________________________________________
_______ _______ _______ _______

  1. Activity __________________________________________________________________________________

Leadership Role (if any) _____________________________________________________________________
Section 7—Short Answer
What activity, volunteer position or job have you participated in over the last 4 years that is related to or preparing you for your career goal? Explain. __________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________



ETMC-Quitman Auxiliary Scholarship Recommendation Instruction Sheet

(to be written by a counselor, pastor, employer, teacher or professor )

The following individual has applied for an Auxiliary scholarship to further his/her education and has named you as a person who might evaluate his/her suitability for this scholarship. Under a separate sheet, please write your recommendation which should include information concerning the applicant’s character, activities, work ethic, attitude and other pertinent facts touching upon his/her past achievements and future potential.


Please include your name, title, and contact information including phone number and email address. Your recommendation can be submitted in any format you choose, and you are not required to return this Instruction Sheet. Your comments will be most helpful in the scholarship selection process and will be kept

confidential.


APPLICANT: _______________________________________


Questions:
Debby Keenan, Scholarship Chairman

(903) 383-5064 or ddktk@verizon.net


Judy Johnson, President of ETMC-Quitman Auxiliary

(903) 383-3433 or judydougj@yahoo.com



Mailing Address:
Auxiliary Scholarship Chairman

c/o Volunteer Services

ETMC-Quitman Auxiliary

117 N. Winnsboro Street



Quitman, Texas 75783

Postage paid return envelope provided will be provided by applicant.

High School Application Deadline: Postmarked on or before April 20, 2015.

ETMC-Quitman Auxiliary Scholarship Recommendation Form

(To be completed by an ETMC-Quitman Auxiliary Volunteer (for junior and shift volunteers only) or


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