Heart of Illinois Chapter 2016 Scholarship Application STUDENT APPLICATION STUDENTS: Please complete all sections of the application. The deadline for submission is a postmark date of no later than April 20, 2016. SECTION 1 PERSONAL INFORMATION Name: Date of Birth: Student ID Number: Permanent address: Home Phone: Alternate Phone: Email address: SECTION 2 ACADEMIC INFORMATION Name of High School: GPA: High School Rank: out of ACT Score: Anticipated UW major(s): 1
SECTION 3 ACTIVITIES AND INTERESTS A. List and briefly describe your high school extracurricular activities (e.g. memberships in organizations, sports, etc.): Organization Involved Position Held Date of Involvement Brief description of your responsibilities: B. List and briefly describe volunteer activities in which you have been involved: Organization Activity Date of Involvement Brief description of how you participated: 2
C. List honors or academic awards you have received (e.g. scholarly activities, research, etc.): Award/Honor Institution/Organization Date D. List and briefly describe any work experience: Position Employer Dates of Employment Brief description of your work responsibilities: 3
SECTION 4 SHORT ESSAYS Maximum word count: 250 per question. A. Why did you choose the University of Wisconsin-Madison? B. How do you feel that the University of Wisconsin-Madison will prepare you for success, both in your intended major and in general? C. How will you be financing your college education and how will a scholarship impact your plans? D. Is there any other information that we should know about you? This is your opportunity to include information that is not contained in other areas of the application. Please be specific. 4
SECTION 5 REFERENCES List the names of references, minimum one; maximum two. Suggested examples of references are employers, ministers, coaches, and teachers. References should not be family members or peers. Name of First Reference (Required) Address Phone Relationship to Applicant Name of Second Reference (Optional) SECTION 6 AGREEMENTS AND AUTHORIZATION If you are awarded a scholarship, do you agree to immediately notify the Heart of Illinois Scholarship Committee if you decide NOT to attend the University of Wisconsin-Madison? YES (Please initial). I authorize the release of all information relevant to my application for this scholarship, and I certify that all information given on this application is true and complete to the best of my knowledge. I also request my high school transcript and other academic information to be provided to the WAA HOI UW-Madison Scholarship Committee. Date Signature of Applicant Signature of Parent or Guardian SECTION 7 SUBMITTING YOUR APPLICATION Please submit your completed application to your Principal or Guidance Counselor to be considered for the Heart of Illinois WAA Chapter scholarship: 1. Completed Student Application Form (pp. 1-5) 2. Completed Principal or Guidance Counselor Application form (p. 6) We recommend that you provide your completed application to your Principal or Guidance Counselor at least one week prior to the application due date. All applications must be postmarked by April 20, 2016. Principals and Guidance Counselors should send all materials to: Terri Benson Scholarship Committee WAA Heart of Illinois Chapter 2711 Arlington Drive Springfield, IL 62704 terribenson@comcast.net 5
Heart of Illinois Chapter 2016 Scholarship Application PRINCIPAL OR GUIDANCE COUNSELOR REFERENCE Counselor/Principal Name: Phone: TO BE COMPLETED BY PRINCIPAL OR COUNSELOR: Please submit a copy of the applicant s transcript. If the following information is not on the transcript, please complete the information below: Student s Full Name: Student s class rank of Student s High School Cumulative Grade Point Average: ACT Composite Score: PRINCIPAL/COUNSELOR NOTE: A STUDENT WILL NOT BE CONSIDERED FOR A SCHOLARSHIP UNLESS A COPY OF THE TRANSCRIPT IS RECEIVED. Please use the space provided to comment on the student s personal and academic development in high school. COMMENTS ARE EXTREMELY IMPORTANT: This application must be postmarked by April 20, 2016. Please direct any questions to Terri Benson at terribenson@comcast.net. Return applications to: Terri Benson, Scholarship Committee WAA Heart of Illinois Chapter 2711 Arlington Drive Springfield, IL 62704 6