Student Application 1. Name First Middle Last 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: Subject Teacher Final Grade List subjects you are taking 2nd semester: Subject Teacher 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. ATTACHMENT #1    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 Occupation 3. Mother's/Stepmother’s Name Occupation 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 expenses? 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 Date 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 Math Writing 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)