Application form

Current high school seniors must return the completed application to the Pupil Services Office at the
Fort Atkinson High School by the deadline for independent scholarships. Applicants who have already
graduated from high school must return the completed application to Helen M. Rose at the address
below by February 15.

        Helen M. Rose, Scholarship Chairman and Program Administrator
        Fort Atkinson Community Foundation
        244 N. Main St.
        Fort Atkinson, WI 53538
        920-563-3210 (office)
        920-563-4926 (home)

Personal Data:


Home Address                                                                                ______

Address at College (if applicable)                                                          ______

Phone                                   Birthdate                                  Present age ____

Email address___________________________________________________________________

Present occupation


Names and ages of dependents (if any)

Name of parent(s) or guardian

        Home address


        Brothers and sisters (state ages and indicate those attending college or technical school)

Revised 2/2011                                      1

                        Name of School                   Years Attended        Year Graduated

High School


College/university at which you plan to use this scholarship

Major course of study

Degree anticipated

How many credit hours are required for graduation?

How many credit hours have you completed? _________

How many credit hours apply to the degree you are presently pursuing?

Anticipated completion date

Are you a full or part time student?

Community Activities & Employment:

Please indicate any school, community or church activities in which you have been
involved. (append resumé or attach extra pages if necessary)

Employment during High School:
                                                       Type of             Hours       Wage
From      To            Employer                        Work              Per Week

Revised 2/2011                                     2
Employment during college:
                                                        Type of            Hours          Wage
From     To           Employer                           Work             Per Week

Financial Data:

Student: Maintains own residence_______ Helps support family_______ Supports self_______

Is your family or some person assisting you with college expenses?
        Completely: yes _____ no_____       Partially: yes ___no ____ If yes/what %_________

Please check the gross income per year of you and family assisting you with college expenses.

____below $9,000    ____$30,000-$59,999 ____$90,000-$119,999 ____$160,000-$199,999

____$9,000-$29,999 ____$60,000-$89,999 ____$120,000-$159,999 ____$200,000-$249,000 ____$250,000+

What will your tuition cost next year?

What other costs are associated with your study?

How much do you expect to need that is not currently available to you?

Other than scholarship or other financial aid, how do you plan to finance your education? What other
financial resources do you have? ___________________________________________________

Indicate any other scholarships or financial aid (including dollar amounts) you will be receiving during
the year.

What alternatives are available to you if you do not receive this scholarship?

Revised 2/2011                                      3
Are there any special family or financial circumstances that the scholarship committee should know
about? (attach extra page if necessary)

Please be sure to include the following items with your application :
       Write an essay that succinctly describes your immediate and long term educational goals,
       your professional and personal ambitions, and what you have done personally,
       academically and financially to prepare yourself to reach your goals and realize your
       ambitions. Explain the value and contribution you feel a scholarship would make toward
       the realization of your goals and ambitions.
       Please include a copy of your high school and (if applicable) your post secondary
       education transcript(s) for work completed to date.
           Test Scores:
           Please include ACT, SAT, and AP exam scores, if known. (Although not required, this information is
           appreciated by the selection review committee.)
           Letters of Recommendation:
           Include two letters of reference from persons (other than relatives) who can speak to your
           character, personality, initiative and your need for financial assistance.

Student’s Authorization:

I have completed this form to the best of my ability, and all questions are answered accurately and honestly. For a fair
evaluation as a scholarship candidate, I hereby release all academic records to the Fort Atkinson Community Foundation.

                                                                     Student’s Signature

Parental Authorization: (for high school students only)

We have checked this form for omissions and errors, and to the best of our knowledge the information reported is complete
and correct. We authorize its transmittal along with all academic records to the Fort Atkinson Community Foundation.

                                                                     Parents’ Signatures

This scholarship does not discriminate against pupils on the basis of sex, race, religion, national origin, ancestry, creed, pregnancy, marital or parental
status, sexual orientation, or physical, mental, emotional, or learning disability or handicap.

Revised 2/2011                                                                 4

To top