2015-2016 Leadership 1000
ELIGIBILITY CHECKLIST
You are eligible to apply for the Leadership 1000 Scholarship if you answer yes to each of the questions below.
Please note that international students, students on foreign exchange or visa are not eligible.
1. I am a Washington state resident , (meeting in-state tuition requirements or eligibility for Washington state financial
aid programs)
Yes
2. I will be enrolling as a college freshman, sophomore or junior in fall 2015
Yes
Please note: if you have completed MORE than 60 quarter credits or more than 30 semester credits in college at the
end of fall term 2014, you are not eligible. Students who have not yet graduated from high school should select “yes”,
even if they have completed college credits.
3. I am planning to attend an eligible four year college or university in Washington state for the fall 2015.
OR
You will be or already are a graduate of a Tacoma public or private high school, or live in the city of Tacoma, and plan
to attend or are already attending a community or technical college in the State of washington, pursuing a degree in
science, engineering, energy efficiency, information technology, nursing, mathematics, pre-med, biology, chemistry,
environmental science, biotechnology, urban planning, architecture, health related majors, or social sciences.
Yes
Please note: If you are attending a community or technical college you should answer yes if transferring to an eligible
four-year college/university for the fall of 2015, or if you are planning to complete a bachelors’ degree program offered
at the community college.
4. I will file or have filed a 2015-16 FAFSA - (Free Application for Federal Student Aid), if eligible to apply.
Yes
Please note: If you are not eligible to apply for the FAFSA, you should answer yes to this question. If you are selected,
alternative financial aid information may be requested by the College Success Foundation.
5. I meet the total family income requirement, (Adjusted gross income plus all untaxed income), for 2014 based on this
chart.
 Family of 1 - $32,500
 Family of 5 - $73,000
 Family of 2 - $43,000
 Family of 6 - $83,000
 Family of 3 - $53,000
 Family of 7 - $85,000
 Family of 4 - $63,000
Yes
Please note: If you qualify to submit the FAFSA as an independent student, the family income amounts are those
reported by you (including spouse and children, if applicable) rather than your parents. Dependent students must
use their parents’ income.
6. My cumulative GPA through fall quarter/semester 2014 is at least a minimum of 2.75.
Yes
7. I am planning to enroll full-time as a college student, 12 credits per quarter, equivalent for semester.
Yes
I checked yes to all the above.
Yes
STUDENT INFORMATION
First Name John
Middle Name Alex
Last Name Smith
Mailing Address 1605 NW Sammamish Rd
City Issaquah
State WA
ZIP Code 98027
Date of Birth 10/10/2001
Country of Birth United States
Gender Male
Social Security Number 333-33-3333
Are you a U.S. Citizen? Yes
Preferred Phone Number 425-416-2000
Type of Phone Number Home Phone
Secondary Phone 425-416-2001
Type of Phone Number Cell Phone
Email [email protected]
Re-enter Preferred Email [email protected]
Note: This must be a valid address that you check regularly. If it changes notify College Success Foundation (CSF)
promptly. Please make sure CSF is an approved sender.
RACE/ETHNICITY
NOTE: The following questions adhere to the U.S. Department of Education standards for gathering information about a
student's race and ethnicity and use the following guidelines:
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American Indian or Alaska Native (a person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment).
Asian (a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam).
Black or African American (a person having origins in any of the black racial groups of Africa).
Native Hawaiian or Other Pacific Islander (a person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands).
White (a person having origins in any of the original peoples of Europe, the Middle East, or North Africa).
Are you of Hispanic/Latino descent (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture/origin, regardless of race)?
Yes/No
Additionally, what race(s) do you consider yourself? Regardless of your answer to the previous question, please mark the
following box(es) to indicate what you consider yourself to be.
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
ACADEMIC INFORMATION
Academic Attendance
Washington state high school from which you have or will receive your high school diploma: Coupeville High School
State: Washington
I am currently a:
High School Senior (Not Yet Graduated from High School)
High school expected graduation date:
06/01/2015
High School Graduate (Not Currently Enrolled in College)
How many college credits have you completed through fall quarter/semester 2014?
 0 to 44 quarter credits OR 0 to 29 semester credits – freshman
 45 to 89 quarter credits OR 30 to 59 semester credits - sophomore
High School Graduate (Enrolled in College)
What college or university are you currently attending?
University of Washington
How many college credits have you completed through fall quarter/semester 2014?
 0 to 44 quarter credits OR 0 to 29 semester credits – freshman
 45 to 89 quarter credits OR 30 to 59 semester credits - sophomore
Grade Point Average
Your cumulative grade point average (GPA) through fall quarter/semester 2014 must be a minimum of 2.75 (on a 4.0
scale).
Enrolled in high school - If you have not yet graduated from high school, enter your high school cumulative GPA
through fall quarter/semester 2014. If you are a Running Start student check with your high school to ensure that your
Running Start credits for fall quarter are included.
Enrolled in college/university - If you are currently enrolled in college/university report your college/university
cumulative GPA through fall quarter/semester 2014. If you attended more than one college, enter the GPA from the
college where you earned the most credit.
Graduated from high school - If you have graduated from high school, but have not yet enrolled in college, enter your
high school cumulative GPA.
Attended college, but not enrolled - If you graduated from high school and attended college, but are not enrolled fall
quarter/semester 2014, enter your most recent college/university cumulative GPA from the college/university from which
you earned the most credit.
Received your GED – Enter the score.
My GPA is from:
High School Transcript
My GPA is: 3.00
College Transcript
My GPA is: 3.25
Please provide GPA through two decimal points e.g. 3.12
GED Score
My GED score is: 3000
Academic Plans
Name of Washington college or university where you will be enrolled during fall 2015: Antioch University
If the college you indicated above is a community college, will you be pursuing a bachelor’s degree from that college?
 Yes
 No
Academic areas of interest: Biology
Intended Major: Molecular Biology
Expected completion date of baccalaureate degree: 06/01/2019
ACTIVITIES
Extracurricular, Personal, and Volunteer Activities
List your top three extracurricular, religious, community, family activities and hobbies. Include specific events and/or major
accomplishments such as musical instruments played, varsity letters earned, etc. You may include activities completed
during the summer.
1. Activity name: Animal Shelter Volunteer
Positions held, honors won, or letters earned: Shelter Assistant
Dates of activity
From: 09/15/2011
To: 06/30/2014
Total hours spent on this activity for the timeframe listed above: 362
Paid Work Experience/Student Income Information
List the top two jobs (including summer employment) you have held during the past three years.
1. Specific job and nature of work: Soccer Referee
Employer: Coupeville Parks and Rec
Date of employment
From: 07/16/2012
To: 12/15/2014
Approximate number of hours spent per week: 12
Honors and Awards
Briefly describe any academic distinctions or other awards you have received during high school or college.
Voted team captain of baseball team
President of the Associate Student Body
Co-editor of Coupeville high school yearbook
FAMILY INFORMATION
Living Situation
Please let us know whether you completed the FAFSA as a dependent or independent student.
You are considered a dependent student, even if you are currently living away from your parents, if your parents were
required to provide financial information when you completed the 2015-2016 FAFSA.
You are considered an independent student if your parents were not required to provide financial information when you
completed the 2015-2016 FAFSA (you may be either living alone, with a child, or with a spouse/partner).
I am/an:
 Independent student
How many people are in your household?
Include:
 Yourself
 Your spouse/partner (if any)
 Any children you support
Total household size
Total Household Size: 1 – 10 people
 Dependent student
Parent/Guardian 1 Information:
Relationship to applicant: Mother
Title: Mrs.
First Name: Ann
Last Name: Smith
Gender: Female
Preferred Phone Number Type: Cell Phone
Preferred Phone Number: 333-333-3333
Marital Status: Divorced
Is this parent employed? Yes/No
Employer Name: Starbucks
Position: Sales Manger
Hours worked outside the home per week: 35
Please click here to enter second parent information: 
Family size information
How many people are in your parents’ household?
Include:
 Yourself
 Your parent(s)
 Your siblings who are under 18
 Your siblings who are 18 or older, if they are currently enrolled in college as undergraduate students (do not
count sibling who are over 18 who aren’t enrolled in college)
 If there are any other individuals living with your parent(s) who are dependent on your parent(s)/guardian(s)
for financial support (grandparent, grandchild, disabled older sibling), you may include them in your family
size.
Total household size
Total Household Size: 1 – 10 people
Parent Information
What was the highest education level either of your parents attained? Graduate Degree
Do either of your parents currently work in the agricultural industry? Yes/No
Are you currently placed in, or have you emancipated from foster care? Yes/No
FINANCIAL INFORMATION
Family Annual Income
 If you are a dependent student, answer the questions below based on your parents’ information
 If you are an independent student, answer the questions below based on yourself
 If you are a married student, answer the questions below based on yourself and your spouse/partner
Federal income tax filing status for 2014: Have or will file a 1040, 1040A, or 1040EZ
1. Adjusted Gross Income: 20000
2. All untaxed income
a. Child support received: 1000
b. Worker's Compensation or disability: 1000
c. Housing, food and other money received for living expenses [please enter source(s)]: 1000
Source(s): Money from grandparents for living expenses
3. Child support paid (deduct): 1000
Please calculate total annual income. This is the sum of the adjusted gross income (1), plus any untaxed income
(2 (a - c)), minus any child support paid (3):
4. Total Annual Income for 2014 (please calculate): 22000
Maximum 2014 income levels (Adjusted gross income plus all untaxed income) for L1000 eligibility
 Family of 1 - $32,500
 Family of 2 - $43,000
 Family of 3 - $53,000
 Family of 4 - $63,000
 Family of 5 - $73,000
 Family of 6 - $83,000
 Family of 7 - $85,000
SHORT ANSWERS
Short Answer Introduction
Minimum of 150 and a maximum of 300 words are required for each short answer question before the application can be
submitted. We strongly recommend that you do the following:
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Read all the questions first.
Outline your response to each question before you begin writing, making sure to address all parts of the question
fully and completely.
Use different examples in different responses to build the most complete picture of yourself as a unique student
applicant. The more details you include, the stronger your answers will be.
Write drafts of each short answer. If it’s easier for you, you can write them in word and paste them into the boxes
below.
Share draft with a teacher or relative.
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Short Answer Question 1
What are your educational and career goals? What specific steps have you already taken on the path to reaching them?
Short Answer Question 2
Describe a strength that will help you achieve your educational/career goals and provide examples that demonstrate how
you have continued to develop this strength. Discuss a weakness that may prevent you from achieving your
educational/career goals and the steps you have taken to address that weakness.
Short Answer Question 3
When confronted with a need for support and advice, what living person do you turn to for guidance? Describe a recent
difficult situation when that person helped you. If he or she did not have the knowledge to help you, what would you do
next?
Short Answer Question 4
Explain how you contribute to the well-being of your family, school, workplace, community, or place of worship. What have
you gained and/or learned from that experience?
Short Answer Question 5
Describe a time when you faced a personal challenge and share in detail how you worked through the situation. What if
anything did you learn from this experience and how has it influenced your day-to-day actions and/or goals for the future?
Tacoma Short Answer Question
Do you live in the city of Tacoma OR will you graduate or have already graduated from a public or private high school in
the city of Tacoma?
Yes/No
Are you planning to pursue a major in science, engineering, energy efficiency, nursing, mathematics, pre-med, biology,
chemistry, environmental science, biotechnology, urban planning, social sciences, architecture, information technology or
health related majors?
Yes/No
Approximately 6 scholarships will be awarded to students from the Tacoma area who are going into the specific majors
noted in the previous question. Recipients of this scholarship will also be required to participate in a one-week, unpaid
internship with the city of Tacoma at a Tacoma location. Please complete the short answer question to be considered.
Short Answer
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Please describe why you are interested in majoring in one or more of the required fields mentioned above.
What do you hope to learn from the required one-week, unpaid internship?
Would the receipt of this scholarship and participation in the internship help influence you to return and work in
the Tacoma area after graduation? If so why?
RECOMMENDATION
Personal Recommendation
For the personal recommendation, you should choose an adult who has insight into your personal character as well as
your family history. A good option may be a counselor, coach, pastor, employer or teacher who knows you particularly
well. A family member, relative, significant other, College Success Foundation employee or peer may not serve as
your personal recommender.
Directions:
Step one: Enter the first name, last name, and email address of the recommender:
First name: Rod
Last name: Merrell
Email address: [email protected]
Step two: Download the recommendation form by clicking the link below.
You may either print the form, fill out your name and city, and deliver it to your recommender to complete, OR you can
save the PDF and email it as an attachment to your recommender.
Your recommender must submit both the completed cover sheet and their letter of recommendation directly to the College
Success Foundation.
Please let your recommender know that recommendations must be postmarked by March 9, 2015 for your application to
be considered complete. You may want to check in with your recommender again before March 9 to make sure they will
be able to submit it in time.
Note: Postmarked by March 9 means date-stamped by the post office on or before March 9. If you wait until the day of
March 9 to mail it, you may need to deliver it to the post office during business hours to make sure it is date stamped by
the ninth.
APPLICATION CHECKLIST
Application Document Requirements
1. Recommendation
I have either emailed or delivered the Personal Recommendation Form to my recommender, and he/she
understands that it must be postmarked by March 9, 2015:
 Yes
2. Transcript
If you are currently in high school or if you have not yet completed any college credits, you must submit a
current official high school transcript, showing all of your classes through fall quarter/semester 2014. If you are a
Running Start student check with your high school to ensure that your Running Start credits for fall quarter are
included. You may need to request an official transcript from your high school a couple of weeks in advance, so
be sure to plan ahead.
If you are currently enrolled in college, you may submit an unofficial transcript, but it must show all your classes
through quarter/semester 2014, and include your cumulative GPA.
If you graduated from high school and attended college, but are not enrolled fall quarter/semester 2014, you
must submit your most recent college transcript that includes your cumulative GPA.
Please mail your transcript to:
College Success Foundation
Leadership 1000 Scholarship
1605 NW Sammamish Road, Suite 200
Issaquah, WA 98027
Your transcript must be postmarked by March 9, 2015 for your application to be considered complete.
Note: Postmarked means that the envelope must be delivered to the post office before it closes for the day, or
placed in a mailbox before the last pickup of the day.
I will mail my high school (official) or college (unofficial) transcript to the College Success Foundation by March 9,
2015.
 Yes
AGREEMENT/CONSENT
Pledge of Authenticity, Agreement and Consent
If you are under the age of 18 at the time of this application, you must have a parent/guardian sign below.
By my/our signature on this form I/we pledge that:
 The statements made and circumstances represented throughout the applicant’s entire application are truthful to the
best of my/our knowledge.
 The essays accompanying this form are substantively the applicant’s own work, although they may have been
reviewed by parents, teachers or other advocates.
 All of the financial information I/we have provided is complete and accurate.
By my/our signature on this form I/we understand and agree that:
 The information submitted in this application will be reviewed by College Success Foundation (CSF) staff and
outside consultants for the purposes of selection.
 Prior to candidate selection, CSF staff may be in contact with school officials to confirm that the applicant’s school
attendance and conduct have been at the high level expected by the program. This information may be taken into
consideration in the selection process.
 One of the outcomes of the scholarship program is to increase knowledge regarding higher education opportunity
through research, and the applicant may be contacted by outside consultants in the future and asked to participate in
research surveys whether or not they are selected for the Scholarship.
 All income and asset figures are subject to verification by the CSF staff. If requested, your family may need to
provide official copies of federal income tax returns and other documents to CSF.
 In January or February of each year while you are in school, your family will need to complete a form called the Free
Application for Federal Student Aid (FAFSA) http://www.fafsa.ed.gov. If CSF learns from the college the applicant
will be attending that the income or asset figures provided on the FAFSA differ by more than small amounts from the
information submitted in this application, the Foundation reserves the right to terminate the applicant’s participation
in the Leadership 1000 Scholarship program. The Foundation also reserves the right to not make a monetary
scholarship award if the applicant is ultimately ineligible for need-based financial aid.
 If at any time information provided in this application is found to be false or inaccurate, it is sufficient cause for
rejection or dismissal from the scholarship program.
By my/our signature on this form I/we consent to:
 The use of any and all information from this application in connection with CSF research activities. The applicant’s
individual transcript and financial information will not be made available to the public through CSF research activities
in a form that would allow the applicant to be identified, although research results may be made available to the
public in an aggregated form, such as an average or a total for a group of students.
 I, the undersigned student, irrevocably give CSF the right to (1) share information about me (including my name, my
college admission or enrollment status, my financial aid status, my academic progress including my cumulative
grade point average, my academic major and areas of interest, and other personal and family background
information I provide to CSF or any educational institution I currently attend) and (2) use my name, picture, or
likeness (the “Likeness Materials”) for any program or CSF purpose.
 Further, I authorize my educational institution to release my academic, financial aid, and any other pertinent
educational information to CSF.
 I waive (1) any rights I may have in connection with use of my information or the Likeness Materials, including any
right to own, inspect or approve the form, media or manner of use and (2) any liability resulting from the use of my
information or the Likeness Materials. If I am selected as program participant, I will, upon CSF’s request, sign
additional releases in form and substance acceptable to CSF.
Applicant Agrees: Yes
Applicant First Name: John
Applicant Last Name: Smith
Month: January
Day: 16
Year: 2015
If you are under 18, your parent/guardian needs to sign below.
I am under 18 