application combined.qxp - Lancaster County Community Foundation

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SCHOLARSHIP
PROGRAM
THE PROGRAM
The Lancaster County Community Foundation's scholarship program assists area youth who plan to continue education in
college or vocational school programs. Since 1924, the Community Foundation has made a positive difference in
Lancaster County, helping individuals experience the power of philanthropy and supporting a wide variety of charitable
projects in our community. The Community Foundation is entrusted with millions of dollars of community assets, which
are invested for the long-term benefit of Lancaster County. By inspiring and encouraging local philanthropy, we can work
together to make Lancaster County a better place.
The Lancaster County Community Foundation Scholarship Program is administered by Scholarship Management
Services, a division of Scholarship America. Scholarship Management Services is the nation's largest designer and
manager of scholarship and tuition reimbursement programs for corporations, foundations, associations and individuals.
Awards are granted without regard to race, color, creed, religion, sexual orientation, age, gender, disability, or national
origin. Scholarship Management Services assists Community Foundations in expanding educational opportunities and
encouraging educational achievement.
ELIGIBILITY FOR ALL SCHOLARSHIPS
Applicants to The Lancaster County Community Foundation Scholarship Program must be residents of Lancaster County
and high school seniors or graduates of a high school in Lancaster County, who are already enrolled or planning to enroll
in a full-time course of undergraduate study at an accredited two- or four-year college, university, or vocational-technical
school. Applicants must have a cumulative grade point average of 2.5 or better on a 4.0 scale.
SCHOLARSHIPS
1.
JOSEPH AND CLAUDINE HESS SCHOLARSHIP
Students from all schools in Lancaster County, Pennsylvania are eligible for this $2,000 per year renewable
scholarship (see note below under AWARDS). Scholarships are offered each year for full-time study at an
accredited institution of the student's choice. Please check the applicable box on the application page.
2.
ALBERT S. ROSMAN SCHOLARSHIP
Students attending Conestoga Valley High School in Lancaster County, Pennsylvania are eligible for this one time,
Freshman Year Scholarship of $1,375. Scholarship is offered each year for full-time study at an accredited
institution of the student's choice. Please check the applicable box on the application page.
3.
JAMES R. BUESCHER SCHOLARSHIP
Students attending all schools in Lancaster County planning a course of study in Creative Writing are eligible for this
$475 one time, Freshman Year scholarship. Scholarships are offered each year for full-time study at an accredited
institution of the student's choice. Please check the appropriate box on the application page.
4.
GEORGE W. McKIBBIN SCHOLARSHIP
African American students attending all schools in Lancaster County, Pennsylvania are eligible for this $2,000 per
year renewable scholarship (see note below under AWARDS). Scholarships are offered each year for full-time study
at an accredited institution of the student's choice. Please check the appropriate box on the application page.
AWARDS
Scholarship awards are grants, not loans. The award may be used for educational expenses for one entire year of fulltime study. Awards may be renewed (unless otherwise noted) up to three additional years or until a bachelor's degree is
earned, whichever occurs first. Awards may not be deferred.
Renewal (for noted funds) is contingent upon continuing to meet the program requirements (including financial need)
and maintaining a cumulative grade point average of 2.5 or better on a 4.0 scale in a full-time course of study. Awards
are for undergraduate study only.
APPLICATION
In addition to accepting transcripts from the school, Scholarship Management Services accepts printed transcripts
obtained online. These transcripts must include the student's name, the name of the school, and grades broken down by
semester.
Applicants are responsible for gathering and submitting all necessary information. Applications are evaluated on the
information supplied; therefore, answer all questions as completely as possible. All information received is considered
confidential and is reviewed only by Scholarship Management Services, The Lancaster County Community Foundation
and PHEAA.
SELECTION OF RECIPIENTS
Scholarship recipients are selected on the basis of financial need, academic record, demonstrated leadership and
participation in school and community activities, honors, work experience, a statement of goals and aspirations, and an
outside appraisal. Financial need will be a priority.
Applicants are welcome to apply for awards from all funds for which they are eligible (by checking the appropriate boxes),
but they will receive a maximum of one (1) scholarship grant in a given year.
Selection of recipients is made by Scholarship Management Services. All applicants agree to accept the decision of
Scholarship Management Services as final. Applicants will be notified in early April whether or not they have
been selected to receive an award.
PAYMENT OF SCHOLARSHIPS
Scholarship Management Services processes scholarship payments on behalf of the Lancaster County Community
Foundation. Payments are made in two equal installments on August 15 and December 30. Checks are mailed to each
recipient's home address and are made payable to the school, for the student.
OBLIGATIONS
Recipients have no obligation to the Lancaster County Community Foundation. They are, however, required to supply
Scholarship Management Services with complete transcripts and to notify Scholarship Management Services of any
changes of address, school enrollment, or other relevant information.
REVISIONS
The Lancaster County Community Foundation reserves the right to review the conditions and procedures of this
scholarship program and to make changes at any time including termination of the program.
ADDITIONAL INFORMATION
Questions regarding the scholarship program should be addressed to:
Lancaster County Community Foundation
Scholarship Program
Scholarship Management Services
One Scholarship Way
Saint Peter, MN 56082
Telephone: (507) 931-1682
Lancaster County Community Foundation
Scholarship Program
INSTRUCTIONS FOR COMPLETING THE FINANCIAL DATA SECTION OF THE APPLICATION
The Financial Data section of the application should be completed by the employee. Information should be
from a completed tax return or based on estimated information to be filed with the IRS.
1. STATE OF RESIDENCE is the state where the parents reside and pay state income tax.
2. ADJUSTED GROSS INCOME can be found on IRS FORM 1040 and is gross income reduced by specific
adjustments allowed by law.
3. TOTAL FEDERAL TAX PAID includes the total amount of federal income tax to be paid as reported on IRS
FORM 1040. This is not the amount withheld from employee paychecks. (The amount withheld should be
adjusted by any refund or additional taxes due.) Do not report state income tax.
4. TOTAL INCOME earned should be reported individually for both parents. If the student resides with only
one parent, Scholarship America prefers to receive financial information from both natural parents, when
possible. Financial information must be received from the parent who claims the child as a dependent for tax
purposes. If a parent has remarried, the spouse's information is required if the spouse is a legal guardian of
the student, or claims the student as a dependent, or the student is included in the spouse's benefit plan. If
necessary, two Financial Data sections may be submitted by the student. A copy of the Financial Data section
may be made in order for one to be completed by each parent.
5. UNTAXED INCOME AND BENEFITS include any other income or benefits not included in the adjusted
gross income figure. Do not include untaxed contributions to retirement plans.
6. MEDICAL AND DENTAL EXPENSES include only those expenses not paid by insurance. Do not include
premium payments.
7. TOTAL CASH, CHECKING, SAVINGS, CASH VALUE OF STOCKS, ETC. include liquid assets that can be
used for educational expenses. Not included are IRA, 401K, or other retirement plan funds.
8. TOTAL NUMBER OF FAMILY MEMBERS living in the household and primarily supported by the reported
income includes dependent college students living away from home.
Be sure to check the appropriate box giving the current marital status of the parents from whom the financial
information is submitted. Include the total number of all family members attending post-secondary school at
least half time. (Post-secondary includes any two- or four-year college or vocational school.) Be sure to
include the applicant in this number.
NOTE: Any exceptions to providing financial information as instructed above must be submitted to Scholarship
Management Services in writing.
administered by
10/08
Lancaster County Community Foundation
Scholarship Program
TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES
Completeness and neatness ensure your application will be reviewed properly.
I.D. #
FOR
SMS
USE ONLY
AA
Application postmark deadline January 15
RIC/CS
PD
GPA
SATCR
Albert S. Rosman (Students attending
Conestoga Valley High School)
First Name
Apartment #
City
State
PA
Zip
e-mail address
Phone (717)
White
American Indian/Alaska Native
Black/African American
Multi
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Last Name
First Name
City
Address
Zip
State
Relation to Applicant
Day Telephone
HIGH
SCHOOL
DATA
Year
Day
Date of Birth: Month
PARENT OR
GUARDIAN
INFORMATION
(If not applicant)
TOTAL
Middle Initial
Permanent Home Mailing Address
Check all
that apply
ACTC
George W. McKibbin (African American students
attending all Lancaster County schools)
Last Name
APPLICANT
DATA
SATW
James R. Buescher (Students attending all Lancaster
County schools planning a course of study in Creative
Writing)
Joseph and Claudine Hess (Students attending
all Lancaster County schools)
CHECK
ALL THAT
APPLY
SATM
High School Graduation Date: Month/Year
School Name
Guidance Counselor
POSTSECONDARY
SCHOOL
DATA
Name of post secondary school you plan to attend. (If unknown, please list in order of preference the schools to which you have applied.)
Use official school names. Do not use abbreviations.
School
City
State
School
City
State
Year in school next year:
4 yr. College or University
Vocational-Technical School
2 yr. Community/Jr. College
Other
1
Explain:
Student will:
Bachelor
live on campus
Associate
live off campus
If school choice is a public institution, applicant will pay:
Other
3
4
5
Expected Graduation
Date: Month/Year
Major or Course of study
Degree Sought:
2
Explain:
Commute from home
in-state resident tuition
out-of-state tuition
If space provided in any section is inadequate, you may continue on additional sheets of paper using the same format. DO NOT repeat information
already reported on the application form. Your name, address and name of this scholarship program should be included on all attachments. Sending a
resume does not replace any part of this application.
LANCASTER CO 22B 10/08
1
WORK
EXPERIENCE
ACTIVITIES,
AWARDS
AND
HONORS
GOALS
AND
ASPIRATIONS
Describe your work experience during the past four years (e.g., food server, babysitting, lawn mowing, office work). Indicate dates of
employment for each job and approximate number of hours worked each week.
To
From
Employer/Position
Hours per Week
Were you paid?
Yes
No
Yes
No
Yes
No
Yes
No
List all school activities in which you have participated during the past four years (e.g., student government, music, sports, etc.). List
all community activities in which you have participated without pay during the past four years (e.g., Boy/Girl Scouts, hospital
volunteer, Special Olympics). Note all special awards, honors and offices held. Indicate whether high school or college activities.
Activity
# Years Participating
Special Awards Honors
Offices Held
Make a brief statement or summary of your plans as they relate to your educational and career objectives and long-term goals.
UNUSUAL
CIRCUMSTANCES
APPLICANT
APPRAISAL
(REQUIRED)
Please describe how and when any unusual family or personal circumstances have affected your achievement in
school, work experience, or your participation in school and community activities.
To the Applicant: This section is required and must be completed in the format provided. If incomplete, your
application will not be evaluated. Please print this page and have it completed by a high school or college
counselor or advisor, an instructor or a work supervisor who knows you well.
To the Adult Appraiser: You have been asked to provide information in support of this application. Please give
immediate and serious attention to the following statements. When complete, please return to applicant. If you prefer,
photocopy this section and return to applicant in a sealed envelope. A letter of recommendation does not replace this
section.
The applicant's choice of a post secondary educational program is
excellent
good
fair
poor
The applicant's achievements reflect his/her ability
extremely well
very well
moderately well
not well
The quality of the applicant's commitment to school and/or community is
excellent
good
fair
poor
The applicant's respect for self and others is
excellent
good
fair
poor
The applicant's ability to set realistic and attainable goals is
excellent
good
fair
poor
The applicant is able to seek, find, and use learning resources
extremely well
very well
moderately well
not well
extremely well
very well
moderately well
not well
excellent
good
fair
poor
The applicant demonstrates curiosity and initiative
The applicant demonstrates good problem-solving skills, follows
through, and completes tasks
Comments
Signature
Appraiser's Name
LANCASTER CO 22B 10/08
2
TRANSCRIPT
INFORMATION
A complete transcript of grades must be sent with this application. Grade reports are not acceptable.
1. Students currently or previously enrolled in college or vocational-technical school must include all college or vo-tech
transcripts of grades from each school attended. Online transcripts must display student name, school name, grade and credit
hours earned for each course, and term in which each course was taken. (Completion of high school information below is not
necessary.)
2. High school seniors and students who have completed less than one full quarter or semester of post-secondary
education must include a high school transcript of grades and have this section completed by the appropriate school official. (A
clear explanation of the school's grading scale must also be submitted.)
in a class of
School Official's
Signature:
Weighted
/4.0 scale
Unweighted
/4.0 scale
Date
PARENTS'
FINANCIAL
DATA
(REQUIRED)
Math
English
Math
Reading
Science
Composite
Phone
Title
State
Zip
6. Medical and Dental Expenses Not Paid by
Insurance (exclude premiums)
2. Adjusted Gross Income (Form
1040)
Refer to
brochure for
instructions
for completion
assistance.
Writing
The applicant's parents (or student, if independent) must complete this portion of the application. A copy of page one of the most
recent federal tax return form 1040 must be included. If the student applicant is not claimed as a dependent of the associate,
the claiming parent or the student, if independent, must also submit the first page of his or her federal tax return. Adjusted
gross income and total federal income tax amounts should be from most recently filed tax return. To be considered for an award,
this section must be filled out completely.
1. State of Residence
7. Total Cash, Checking, Savings, and Cash Value of
Stocks (exclude retirement plan funds, IRA, 401K)
3. Total Federal Tax Paid (Form
1040) (Not the amount withheld
from paychecks)
8. Total number of family members living in the
household and primarily supported by the
reported income
4. Total Income of Father
9. Marital status of parent or guardian:
Total Income of Mother
Married
5. Yearly Untaxed Income and Benefits
(Please indicate source):
Social Security
Other
OTHER
AWARDS
Critical
Reading
City
Address
ACT
SAT
Cumulative Grade Point Average
Applicant Ranks
Child Support
Divorced
Separated
Widowed
Single
10. Total number of family members attending college at least half
time during the next school year (include applicant, exclude parent)
$
Please list the name and annual amount of any grants or scholarships you have been awarded for the coming school year only.
Name of Award
School to which award will be applied
Amount
Check One:
Granted
Granted
APPLICATION
CHECKLIST
The student is responsible for submitting all materials to Scholarship Management Services on time. Incomplete applications
will not be evaluated. This application becomes complete and valid only when SMS has received all of the following materials:
Student Application with completed Applicant Appraisal
All materials, including transcript, must be addressed to
First page of most recent federal tax return form 1040
Lancaster County Community Foundation
Scholarship Program
Scholarship Management Services
One Scholarship Way
St. Peter, MN 56082
Current Complete Transcript(s) of Grades
(including grading scale)
Printed transcripts obtained online are now acceptable, please see
Application section on the second page of this document.
Postmark deadline January 15
Scholarship Management Services has the sole responsibility for selecting recipients based on criteria as set forth in the
CERTIFICATION program's descriptive brochure. This application becomes the property of Scholarship Management Services. (It is recommended
that you keep a copy for your files.)
I acknowledge decisions of Scholarship Management Services are final. I certify that I meet the eligibility requirements of the
program as described in the brochure and that the information provided is complete and accurate to the best of my knowledge. If
requested, I will provide proof of information I have given on this form. Falsification of information may result in termination of any
award granted.
I understand information from my application and transcript may be reviewed by Lancaster County Community Foundation.
I acknowledge that the Lancaster County Community Foundation is authorized to provide all information to PHEAA for eligibility for
the state PATH Program, the school you will attend or for local press coverage both print and electronic publication of awards
including photos.
Date
Applicant's Signature
Date
Parent's Signature
LANCASTER CO 22A 10/08
Copyright 1988 Scholarship Mangement Services
3
All Rights Reserved

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