Student Application

Student Application
1. Name
2. Social Security Number (optional)
3. Date of Birth
4. Address
5. Father's Name/Address
Mother's Name/Address (if different)
6. Student resides with
7. List Institutions to which you have applied
Institution you hope to attend
Intended major
Have you been accepted?
If you have not been notified, when do you expect to receive a decision from the institution?
8. What is the approximate annual cost of the following at the institution you plan to attend?
Include the total budget amount used by colleges for figuring the financial aid package--ex: tuition, room and board or commuter expense, books, fees, other costs
1st choice school
2nd choice school
9. Do you plan to work part time while attending college and/or during the summer?
10. What are your career plans?
Student Application - page 2
11. What activities have you participated in that demonstrate good citizenship?
12. List subjects you completed 1st semester and the final grade you received:
Final Grade
List subjects you are taking 2nd semester:
13. Please state briefly why you need this scholarship to continue your education/training:
14. Are either or both of your parents members of the organization that is awarding this scholarship?
15. Completed Student Activity Profile sheet (page 3)
The above information is true to the best of my knowledge
Student Signature_________________________________________ Date___________________
Page 3
Student Activity Profile
Substitute your computer generated or typed Student Activity Profile sheet listing the
following information:
1. School Related Activities
2. Community and/or Church Activities
3. Special Awards including Local, District, State and National Honors
Label it Page 3 and use the above heading for your title
If you want a copy of the Activity Sheet Mrs. Warren has on file to help you with this one –
ask Mrs. Warren or Mrs. Lukasavage in the School Counseling Office.
Substitute your essay page for this page
At the top of your page put Attachment #1
Type in the essay question underneath the Attachment title. If an essay topic is not
provided, use the following:
What are your important goals in life and what has led you to
consider these goals as important?
(This may include some family background which has been a
significant influence in your life.) If you have decided on an
occupation or profession, please include your reasons for selecting
this occupation or career. What plans have you made to reach your
goals or stated profession?
Compose your essay (suggested you submit one page double spaced)
Insert your essay page (if required) as your first attachment to your application
Attachment # 2-PARENT FINANCIAL DATA (Note to Selection Committee: This information is
confidential and only to be used within the committee for your selection process)
TO BE COMPLETED BY PARENT(s) or GUARDIAN (This section is to be completed only for
scholarships where financial information is requested by the organization or individual awarding the
scholarship to help determine financial need.) 1. If your parents are both living and married to each other,
answer the questions about them 2. If either parent is deceased and your widowed parent has remarried,
answer the questions about your parent and stepparent 3. If your parents have divorced or separated,
answer the questions about the parent you lived with more during the past twelve months; or if you have
lived an equal time with both, who provided more financial support. 4. If the parent you list has remarried,
answer the questions about that parent and stepparent.
1. With whom does the student reside?
2. Father's/Stepfather’s Name
3. Mother's/Stepmother’s Name
4. Approximate combined income:
over $60,000
$50,000 -- $60,000
$40,000 -- $49,000
$30,000 -- $39,000
$20,000 -- $29,000
less than $20,000
5. How much of income / savings / assets will you be able to apply to the applicant's college
6. How many dependent children are in the family including the student applicant?
7. How much will the student be able to contribute?
8. Have you or do you intend to file a Federal Financial Aid Form (FAFSA)?
9. If yes, based on the FAFSA formula, what is your Expected Family Contribution?
10. If there are any special circumstances that require the need for financial assistance in order for
this student to further his/her education, please explain briefly.
11. Has the student applied for other scholarships?
If the student has been notified of any scholarships or grants that he/she will be awarded
please list below:
The above information is accurate to the best of my understanding of this form.
Signature of Parent
GUIDANCE DEPARTMENT FORM (The following confidential information is being released with student
and parent permission and is to be used only within the scholarship selection committee)
Fill in your name and
diploma type only.
Mrs. Warren will
complete this page
1. Student's Name
2. *Type of Diploma
Advanced Studies Diploma or
3. Cumulative Grade Point Average is
a rank of
in a class of __120__
Standard Diploma
on a 4.0 scale as of February 2010 with
4. Highest College Board Scores (SAT) Critical Reading
Possible Score Range is 200-800 on Critical Reading , 200-800 on Math, and 200-800 on Writing
5. Student Program of Studies Information (Codes: AC-Academic, H-Honor, Dual Enrollment (earns both high
school and college credit) C or AP-Advanced Placement (equivalent to college level in difficulty)
(Highest level for this student is circled)
Highest Level English
English 12
AP English Literature and Composition
Highest Level Math
Computer Math
Geometry or Honors Geometry
Algebra II or Honors Algebra II
Trigonometry / Probability & Statistics
Probability and Statistics (dual enrollment with LFCC)
Pre-Calculus I & II (dual enrollment with LFCC)
Calculus I & II (dual enrollment with LFCC)
Highest Level Social Studies
VA & U.S. History U.S. History (dual enrollment with LFCC)
AP United States History
VA & U.S. Government AP U.S. Government
Highest Level Science
Biology or Academic Biology
Ecology/Biology II
Chemistry Physics
AP Biology
AP Chemistry
Highest Level Foreign Language
(At Luray High School)
Art Band / Chorus/ Guitar Business Technology Leadership Development
Agricultural Education Family & Consumer Science Yearbook Teacher Assistant
Cooperative Technical Education Adv. Physical Education Technology Education
GIS/GPS Geospatial Research Seminar (dual enrollment with JMU)
(At Page County Technical Center)
Auto Service Tech
Criminal Justice Cosmetology Health Assistant LPN Electricity
Elective Areas
Virtual Virginia classes _______________________________________________________________
Attended Massanutten Regional Governor’s School for Science and Technology ½ day program 11 th & 12th grades
High School
Luray High
Counselor’s Signature
*The Standard Diploma requires completion of 22 credits in grades 9-12 with a minimum of 4 units of English, 3 units of Social
Studies, 3 units of math, 3 units of science, 1 unit of Career and Technical Ed., 2 units of Phys. Ed., and 6 electives (two of which
must be sequential). Six verified credits are needed. (2 English , 1 math, 1 science, 1 social studies and 1 of choice)
The Advanced Diploma requires completion of 24 credits in grades 9-12 with a minimum of 4 units of English, 4 units of Social
Studies, 4 units of Math (Algebra I, Geometry, Algebra II), 4 units of Science (Earth Science, Biology, Chemistry), 3 years of one
Foreign Language or 2 years each of two Foreign Languages, 1 unit of Career and Technical Ed., 2 units of Phys. Ed., and 2 electives.
Nine verified credits are needed. (2 English, 2 math, 2 science, 2 social studies, + 1 of choice)