1 Montgomery County Ohio College Promise Montgomery County Ohio College Promise Scholarship Program Application Montgomery County Ohio College Promise applicants must: Be currently enrolled in school as an eighth grader and plan to attend a high school in Montgomery County that participates in the Dayton- Montgomery County Scholarship Program Demonstrate a financial need Attend school regularly Have earned satisfactory grades Be committed to doing their best Montgomery County Ohio College Promise Scholars must: Come prepared to their weekly meetings with an assigned mentor Maintain good grades and a strong record of school attendance Stay Alcohol, Tobacco, Drug, and Crime Free Participate in school co-curricular or extra-curricular activities and/or community/faith based service activities Attend any at-large programs or activities sponsored by the Montgomery County Ohio College Promise program Practice Good Citizenship Maintain a financial need Attain a High School Diploma with a grade point average (GPA) and test scores high enough to meet the entrance requirements of Sinclair Community College, Wright State University, Central State University, Miami University, Denison University, Wilmington College, University of Findlay, Kettering College, University of Dayton, or other 4-year university partners
2 Montgomery County Ohio College Promise Scholars Receive: A Scholarship A full 3-year tuition, fees and books scholarship to Sinclair Community College and the opportunity to earn a 2-year tuition, fees, books and residency scholarship to Wright State University, Central State University, Miami University, Denison University, Wilmington College, University of Findlay, Kettering College, University of Dayton, or other 4-year university partners. A Mentor Adult Mentors will be assigned to each scholar. Mentors will assist and encourage the scholar to reach their full potential. The mentor and the scholar will meet weekly during the school day at the scholar s school. Please call the Montgomery County Ohio College Promise office at or if you have any questions. You can also log on to or or for more information.
3 Applications must be postmarked by November 14, 2015 Please read before mailing in your application as late or incomplete applications will not be considered. To be eligible for the College Promise Scholarship you household income must fall below the amounts shown on the following chart. Income Eligibility Guidelines for 2015* Household Size Annually Monthly Twice per Month Every Two Weeks Weekly 1 21,775 1, ,471 2,456 1,228 1, ,167 3,098 1,549 1, ,863 3,739 1,870 1, ,559 4,380 2,190 2,022 1, ,255 5,022 2,511 2,318 1, ,951 5,663 2,832 2,614 1, ,647 6,304 3,152 2,910 1,455 For each additional family member, add 7, *Income Guidelines Provided by the United States Department of Agriculture Food and Nutrition Service Attach to your application all of the following to establish proof of income for everyone in your household over the age of 18:! A copy of all 2014 Federal Income Tax Returns filed by any members of your household! Proof of Food Stamp eligibility for anyone in your household! Child Support Statements for anyone in your household! Proof of eligibility for TANF Funds for anyone in your household! Unemployment Benefits Statements for anyone in your household! Proof of Disability or Survivor Benefits for anyone in your household! Any other items which can be used to verify your household s income
4 ! Attach the following school information for the student applicant:! 6 th and 7 th Grade Report Cards (grades and attendance records)! 5 th and 6 th Ohio Achievement Assessment test results! 7 th Grade PARCC Testing Results (if available)! Achievement and Ability test results (if available) If you have difficulty obtaining these records, please contact your child s guidance counselor or the principal s office staff. Attach at least 2 recommendations, one of which must be completed by a teacher. Recommendations can be faxed directly to us at Before submitting your application, remember: As this is a needs based scholarship, verify that your family meets the income eligibility requirements (See Income Eligibility Guidelines Chart for 2015). Employment Verification forms must be completed and signed by the Employer. Please contact the Montgomery County Ohio College Promise program office ( or ) if you have questions. The Student Statements section of the application must be filled out by the student in their own hand writing and in their own words. Adult written or typed responses will not be accepted. Students who are selected as finalists and their parent(s)/guardian(s) will be required to attend an interview with the selection committee in January. Mail or hand deliver the completed applications and all attachments to: Montgomery County Ohio College Promise 40 N. Main Street, Suite 500 Dayton, Ohio Applications and attachments must be mailed. Only the recommendation pages can be faxed.
5 Montgomery County Ohio College Promise Student Application Student Information Student Name: First Middle Last Date of Birth / / Address Apartment # Home Phone City Zip Student Address Parent/Guardian Name Cell Phone # Work Phone # Parent/Guardian Address Parent/Guardian Name Cell Phone # Work Phone # Parent/Guardian Address Current School of Attendance Guidance Counselor Contact Information Guidance Counselor Name: Phone Address
6 Student Info: Are you a U.S. Citizen? Yes No What is your Ethnic Origin (Race)? Is English your first language? Yes No If not, what is? Do you speak any other languages? Yes No If yes, what other languages? If you are selected for an interview, will you or a parent/guardian need a translator? Yes No If yes, what language? What Clubs/Organizations are you a member of? Have you ever been suspended (in school or out of school) or expelled from school? Yes No If yes, please explain Have you ever been arrested? Yes No If yes, please explain Does your family plan to move next year? Yes No If Yes: When? Where? What school do you plan on attending in the 9 th grade?
7 Household Information: Mother First MI Last Date of Birth / / Last grade Completed in School Father First MI Last Date of Birth / / Last grade Completed in School Name of Guardian (if different from above) First MI Last Date of Birth / / Last grade Completed in School Student Lives with (please circle all that apply) Mother Stepmother Grandmother Guardian Father Stepfather Grandfather Foster parents Other Number of Brothers Number of Sisters
8 Please list the people living in the home other than the student applicant: Name Age Relationship Last Grade Completed Other Siblings living outside of the home: Name Age Brother Sister Currently Last Grade Attending Completed School Yes No Yes No Yes No Yes No Yes No Yes No
9 Employment Information Parent/Guardian s Current Employer Name of Parent/Guardian: Employer (Company Name): Occupation: Business Address: Number of Years with Current Employer Gross Monthly Salary (before any taxes or deductions) Parent/Guardian s Current Employer Name of Parent/Guardian: Employer (Company Name): Occupation: Business Address: Number of Years with Current Employer Gross Monthly Salary (before any taxes or deductions)
10 Financial Information What is your total annual (yearly) household income (include all household members)? Are you eligible for any Federal Assistance Programs? (Please circle all that apply) Food Stamps TANF Medicaid SSI or SSA Other: If yes, please list the type of service and the amount received per month. (Attach proof of this income to the application) Type of Service Amount per Month Do you receive or are you supposed to receive child support or alimony? Yes No If yes, how much per month (attach proof of this support to the application)? Do you pay child support? Yes No Do you pay alimony? Yes No If yes, how much per month (attach proof of this payment to the application)?
11 Are there any other special circumstances that you would like to share with us about your situation such as: living arrangements, income, etc.? Don t forget to attach your 2014 federal income tax return; evidence of food stamps, child support, TANF, unemployment, disability or survivor benefits; alimony; or any other proof of household income along with the students 6 th and 7 th grade report cards; 5 th and 6 th grade Ohio Achievement Assessment test results, 7 th grade PARCC test results, achievement and ability test results (if available); and 2 recommendations.
12 Family Statement Please print your answers. Write as much detail as possible. If necessary, use additional paper, Apart from the financial impact, explain the importance of your student receiving this scholarship. How will it affect your student and your family?
13 Family Statement (continued) How does your family plan to help the student pursue their college education? Be sure to include any special family circumstances which might contribute to your student being successful. Printed Name Signature of the person submitting the Family Statement Date
14 Student Information (to be completed by the student) Please provide a complete list of your activities, interests, strengths, hobbies, or awards you have received at school, church, community, or work experiences, etc. Please print your information and attach a separate sheet of paper if additional space is needed for your answers
15 Student Statements Write as much detail as possible. Use additional paper if necessary. Answers to the following questions must be handwritten by the student. Each question must be answered. 1. Why do you want to be in this program? 2. Why do you want to go to college? 3. What is your opinion about the value of a good education?
16 4. What is your favorite subject? Why? 5. What do you like to do in your free time? 6. What person do you admire the most?
17 7. What is the most difficult situation you have ever faced? How did you handle it? 8. What is the most difficult situation your family has ever faced? How did you handle it? 9. What concerns do you have regarding college?
18 10. What do you want to be when you grow up? Why? 11. What are your hopes, dreams or goals for the future? 12. Is there any additional information you would like the Selection Committee to know when considering your application? Student Signature Date
19 Student and Parent/Guardian Responsibilities Students In order to be a Montgomery County Ohio College Promise scholar, who will earn a college scholarship and be provided a mentor, every student must sign the following contract and pledge to: Be Alcohol, Tobacco and Drug Free Be Crime Free Practice Good Citizenship Maintain a strong record of school attendance at a Montgomery County High School Participate in school co-curricular or extra curricular activities and /or community/faith based activities Come to the weekly meetings with their assigned mentor Attend any at-large programs or activities sponsored by the Montgomery County Ohio College Promise Program Attain a High School Diploma with a Grade Point Average (GPA) and test scores high enough to meet the entrance requirements of Sinclair Community College and either Wright State University, Central State University, Miami University, Denison University, Kettering College, Wilmington College, the University of Findlay, University of Dayton or other 4-year university partners Bottom Line: Montgomery County Ohio College Promise students are respectful and responsible!
20 Parents/Guardians Parent(s)/Guardian(s) must also make a commitment to their child s success as a Montgomery County Ohio College Promise scholar. Every parent/guardian must sign the following contact and pledge to: Provide a supportive environment at home that will contribute to the success of their child/guardian To develop a positive relationship with school and Montgomery County Ohio College Promise mentor and program staff To attend school related functions including but not limited to open houses, scheduling conferences and parent/teacher conferences Attend any at-large programs or activities sponsored by the Montgomery County Ohio College Promise program Provide releases which will allow to the College Promise Program to receive both academic and disciplinary information from their child/guardian s school, college and university attendance information and for the use of the photographs or video of the student Bottom line: Montgomery County College Promise parents/guardians are involved and engaged, which will have a direct impact on the academic success of their child/guardian! I understand that the information contained in this application is truthful and accurate and will be shared with the Montgomery County Ohio College Promise program staff and the selection committee. I also certify that my child meets the program income requirements. I also understand that any false information in this application will result in my child being dismissed from the program. Student Signature Parent/Guardian Signature Date Date
21 Montgomery County Ohio College Promise Recommendation Form Teacher Statement for Student Please comment on this student s attitude, behavior, and motivation in school. Include the student s ability to maintain at a minimum a 2.5 grade point average and their ability to succeed in post-secondary education. Also feel free to provide any information regarding the student s family situation that the Selection Committee should be aware of. Feel free to call the MCOCP program office at or with any questions that you may have.
22 Printed Name of Teacher Teacher Signature School Grade Level and Subject Taught: Date Phone # Address You may fax this recommendation form directly to the MCOCP program office at
23 Montgomery County Ohio College Promise Recommendation Form Statement of Support for Student Please comment on this student s attitude, behavior, and motivation as it relates to how you know this child. Include the student s ability to be successful in school and their ability to succeed in post-secondary education. Also feel free to provide any information regarding the student s family situation that the Selection Committee should be aware of. Feel free to call the MCOCP program office at or with any questions that you may have.
24 Printed Name of Responder Signature Relationship to the Student Date Phone # Address You may fax this recommendation form directly to the MCOCP program office at
25 Montgomery County Ohio College Promise Employment Verification Form Note to parents/guardians: This form has to be completed for all adults over the age of 18 who live in the same household. The form is to be signed by the employer. Dear Employer: This form is part of an application process for the Montgomery County Ohio College Promise program. The Montgomery County Ohio College Promise program selects deserving students in the 8 th grade, and upon the successful completion of high school and the fulfillment of a student and parent pledge, awards scholarships for attendance at Sinclair Community College, Wright State University, Central State University, Miami University, Denison University, Wilmington College, Kettering College, University of Findlay, University of Dayton, and other 4-year universities. Please take a moment to complete this form in order for your employee s child to be considered. Employee Name Title/Position Length of Employment Salaried Employee Yes No If yes, annual salary: $ If no, hourly rate: $ Typical number of weekly hours; Are there opportunities to receive overtime? Yes No If yes, how often: Name of Company Address City State Zip Phone #
26 Printed Name of Person Completing the Form: Title: Employer Signature Date Feel free to contact the Montgomery County Ohio College Promise office at or with any questions you might have. Revised 7/6/2015 Montgomery County Ohio College Promise
27 Employment Verification Form Note to parents/guardians: This form has to be completed for all adults over the age of 18 who live in the same household. The form is to be signed by the employer. Dear Employer: This form is part of an application process for the Montgomery County Ohio College Promise program. The Montgomery County Ohio College Promise program selects deserving students in the 8 th grade, and upon the successful completion of high school and the fulfillment of both a student and parent pledge, awards scholarships for attendance at Sinclair Community College, Wright State University, Central State University, Miami University, Denison University, Wilmington College, Kettering College, University of Findlay, University of Dayton and other 4- year universities. Please take a moment to complete this form in order for your employee s child to be considered. Employee Name Title/Position Length of Employment Salaried Employee Yes No If yes, annual salary: $ If no, hourly rate: $ Typical number of weekly hours; Are there opportunities to receive overtime? Yes No If yes, how often: Name of Company Address City State Zip Phone #
28 Printed Name of Person Completing the Form: Title: Employer Signature Date Feel free to contact the Montgomery County Ohio College Promise office at or with any questions you might have. Revised 7/6/2015
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