Due by April 10th 3:30 PM annually
Wixson Family Scholarship Application
Based on Ambition, Thrift and Need
Supported by the Umpqua Youth Foundation
Wixson Scholarship History
The Wixsons were a family of 5 children, 3 daughters and 2 sons, none of whom ever married. They moved to Myrtle
Creek, Oregon from New York State around 1906. The Wixson daughters all became school teachers and it was
through their dedication to education that they decided to leave their estate, in trust, to be used to support learning
opportunities for generations to come.
By applying for this scholarship you are agreeing to carry on this dedication to education started by the Wixson
family.
Guidelines (First Time Applicant)
This cover letter must accompany the Wixon Family Scholarship Application. There should be no attachments other
than the two recommendation letters and your transcript.
Any area left blank will receive a "0" for that section. Scholarships must be signed or your application will be
considered incomplete and disqualify you. All information is held strictly confidential.
To qualify, the applicant must have been enrolled at a high school at Days Creek, Glendale, Riddle, South Umpqua,
or Canyonville Christian Academy at the beginning of their senior year. Scholarship recipients must attend a College,
University or Trade School located in Oregon.
The Umpqua Youth Trust Foundation also asks that you return one-half of this scholarship grant after you
have completed your education and are gainfully employed. This should be done in a way that is convenient
for you at that time. This is considered a donation and is tax deductible. This will enable others to benefit
from the Wixon Family Scholarship program. Thank you.
Complete each field electronically. Press [TAB] to move to the next field.
Applicant:
Name
Phone#
Soc. Sec. #.
Cell#
Home address
City
State
Zip
State
Zip
Mailing address
City
School last attended
Planning to attend
General Information:
□ Check if deceased
Father's name
Home address
Occupation
□ Check if deceased
Mother's name
Home address
Occupation
Are you living with a step-parent or guardian other than parents?
If yes, give name and address.
Name
Address
□ Yes
□ No
Wixson Family Scholarship Application
2
List the names of your brothers, sisters, or other persons that depend on your parents for support
Name
Age
Relationship
Attending college
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
Educational Background:
GPA
SAT score
Number in Class
Class Rank
School Activities:
Year
Number of Sports
Number of Clubs
Freshman
Sophomore
Junior
Senior
Special Events Activities List:
List leadership positions you have held in classes, school activities or organizations.
List honors and awards you have received.
Community Service:
List activities and organizations you participated in outside of school.
Wixson Family Scholarship Application
3
Employment:
Include all part-time and/or summer job, babysitting, etc.
Job
Employer
Date (from/to)
Wage
Financial Statement:
Marital Status:
□ Single
Number of dependents:
□ Married
□ Separated
(do not include yourself)
While furthering my education in school I will live:
□ with parents/guardian
□ with relatives
□ on my own
□ campus housing
Estimated expenses
Estimated Income
Tuition & fees
Savings
Books & Supplies
Expected Earnings
Room &Board
Spouses Earnings
Transportation
From Parents
Personal
Scholarships received
Child Care
Other (specify source):
Other (specify)
TOTAL EST. EXPENSES
TOTAL EST. INCOME
Will a parent be enrolled in a post high school education program?
□ Yes
□ No
If yes, please list person
Your parents current adjusted gross annual income is:
(This information is treated as strictly confidential.)
(Line 31, IRS 1040)
EXPLAIN THE TOTAL PLAN FOR FINANCING YOUR EDUCATION. Please include how you propose to fund your
educational expenses beyond the above savings, personal contributions and scholarships.
Wixson Family Scholarship Application
4
Personal Statement:
Please make a concise statement regarding your short and long-term goals for further education and how they relate
to your long term career plans .
What and/or who was most influential in leading you to set these goals? Explain the nature of this influence.
Describe any extenuating financial circumstances that should be brought to the attention of the scholarship selection
committee.
Please print out, sign and add the date to your completed application.
APPLICANT SIGNATURE
Date