Dollars for Scholars Application by HC121001044621


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Directions for the application:
Click save when prompted and save this document to your desktop on your computer.
Using Word, complete pages 6-8 of the application and turn in to the Guidance Office. The
appraisal page should be completed by your reference person and returned to the Guidance
Office. The Due Date For The Application Is November 1.

               Allamakee Dollars for Scholars -- Award Application
By completing the information requested in this application, you will enable us to determine your eligibility
to receive funds provided specifically to help students of the Allamakee Community School District who are
planning to go on to higher education. Typed applications are preferred.

You are responsible for seeing that all supporting documents are completed and submitted by the
deadlines. You must complete your sections of this application and submit them at the WHS Guidance
Office by November 1. At that time, applicants will sign up to participate in specific Dollars for
Scholars chapter activities (if they had not done so previously).

Give the Applicant Appraisal form to the person you have selected to complete that portion of your
application. You are encouraged to select a teacher or other person who is in a position to evaluate you
according to the given criteria, such as an employer, member of the clergy, job supervisor, or others. Arrange
for the evaluator to return the appraisal form to the Guidance Office by the end of first semester.

If any sections of the application are not applicable to your current situation, please attach an explanatory
note. If more space is required for information on any items, you may attach additional pages. Some awards
have a component based on financial need, field of study, activities, etc. Please fill out all sections of the

This application becomes complete only when the following have been submitted: eligibility statement,
personal data sections, applicant appraisal section, and scholarship pledge form.

Eligibility Statement
*1. Applicants are required to attend the Senior Awards Program in May (usually the week
prior to graduation) and the April donor and applicant appreciation breakfast (usually the
first week of April).
*2. Applicants are required to assist with Allamakee Dollars for Scholars fund-raising
community projects during the year. This includes the annual phone-a-thon.
*3. Students not participating in Allamakee Dollars for Scholars projects may not be
eligible for some awards.
*4. In submitting this application, I certify that the information provided is complete and
accurate to the best of my knowledge. The scholarship pledge form will be agreed to,
submitted and followed. Falsification of information may result in termination of any
scholarship granted.
*5. Awards will be given after the completion of the first term, quarter, or semester of
advanced education or as per a specific scholarship's requirements.

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In addition to individual Allamakee Dollars for Scholars awards, the following
scholarships were awarded or administered through Allamakee Dollars for Scholars
in previous years and may again be available this year. In addition, new scholarships
may be established during the year that are not on this list. It is the applicant’s
responsibility to submit any additional forms or information requested for these
scholarships. Any specific deadlines for additional forms will be in the High School

Alice Bechtel Nursing Scholarship—A nursing scholarship in memory of Alice Bechtel is
given. Additional paperwork is required.

Allamakee Community Education Association Scholarships – Two awards are given.
One to a student planning to attend a 4-year college and one to a student planning to attend
a 2-year community college or vocational-technical program.

Allamakee EMT Scholarship - A scholarship, sponsored by the Allamakee County EMT
Association, will be awarded to a student planning to study fire science, paramedic
training, or a related health field.

Allamakee Pheasants Forever – A scholarship is awarded with preference to a student
planning to study in a natural resources or conservation field or a student who themselves
or their family has been active in hunting and conservation organizations.

Allamakee Soil and Water Conservation—One or more awards are made. Selected DFS
applicants complete an essay for scholarship consideration.

American Legion and Auxiliary - An award will be made to a male or female student
who is a relative of a Legion or Legion Auxiliary member. In the event that there is not an
eligible student, the award will not be made that year. Relationship of son, daughter,
grandson, granddaughter, brother, or sister.

Arlin C. Falck Foundation Scholarships – Several awards are given each year based on
the donation amount received from the Foundation. Awards are made to students planning
to study business, finance, accounting, or related fields.

Bennie Fiet Scholarship—An award is made to recognize a longtime donor to Allamakee
Dollars For Scholars.

Bryce M. David Memorial Scholarships –Scholarships in memory of Bryce C. David are
awarded to students meeting criteria related to academics, financial need, and personal
qualities. 2.0 to 3.4 cumulative GPA.

Chantel Snitker Scholarship—One or more scholarships are awarded in memory of
Chantel Snitker, a talented WHS softball pitcher and strong academic student.

Rev. Curtis Webster Scholarship -- This scholarship was established to honor Curtis
Webster, longtime elementary teacher in the ACSD and local minister at Forest Mills

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Methodist Church.

Farmers & Merchants Bank Scholarships – Two scholarships are awarded. Nominees
for Senior Spotlight recognition are made by the faculty. Selection of the recipients is
made from this group and is based on academics, participation, and leadership.

First Presbyterian Church Scholarships – Awards are given to members of First
Presbyterian Church, Waukon. Awards are for two years. Students will receive an award
in their first and second years of study.

St. Patrick’s School Scholarship -- Additional typed paperwork needs to be submitted.
In addition to the Dollars for Scholars application, a short essay and form are used for
selection of the recipients. An award to one male and one female are made if possible.
Please pick up forms at the WHS Guidance Office.

Friends of Waterville Elementary—Two scholarships are awarded to students who
attended Waterville Elementary School.

Good Samaritan Nursing Scholarships – An additional form is submitted in addition to
the Dollars for Scholars application. Scholarships to aid in the study toward a nursing
degree are available through the Waukon Good Samaritan Center, Good Samaritan Society.

John Roys Memorial Scholarship – This memorial scholarship is in honor of long-time
ACSD Agriculture teacher John Roys. Criteria include a student pursuing studies in
agriculture education, or an agriculture field, participation and leadership in FFA and/or 4-

Judy Shelton Memorial Scholarship – A scholarship in memory of Judy Shelton is
awarded to a student planning to study a business career field. Financial need is also a

Kerndt Brothers Savings Bank Scholarships - A scholarship is awarded. Criteria
include scholarship, leadership, school and community participation and service, character,
and citizenship.

Lewis Palmer Scholarship—One or more scholarships are awarded (through 2011) in
memory of Lewis Palmer. Awards are made to deserving resource students pursuing
advanced education.

Lindsey McMillan Scholarship—This scholarship is awarded to a student who has been
active in school, a good student, and a good citizen.

Matilda Durant Music Scholarship—This scholarship is awarded to a student planning to
major in music at Luther College.

Nightcrawlers Forever Scholarship—One or more awards are given by the local service
organization. Criteria may include service, character and financial need.

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Norma Fiet Scholarship—One award is given by her daughters in Norma’s memory to a
student pursuing a career in elementary education.

Orrin and Nancy Grangaard Scholarship—Two awards are made. Consideration is
given to students pursuing math or science careers.

P. E. O. Scholarship – One scholarship is given by the local P. E. O. chapter to a female
student. Criteria include character, leadership, and financial need.

Revelyn Lonning Scholarship—An award is given to recognize a longtime Allamakee
Dollars For Scholars donor. Preference is given to a student planning a career in law

Shirley Angel Golf Scholarship – This scholarship is in memory of long-time girls golf
supporter and wife of WHS’s first girls’ golf coach. Preference is for a member of the girls
golf team.

Spanish Department Scholarship—One scholarship is given to a student who plans to
major or minor in Spanish. Fourth year Spanish students complete an essay for the
selection process.

Waukon Dental Clinic Scholarship – Preference is given to a student planning a career as
a dentist, dental assistant, other related dental health fields, or another health career field.

Waukon Feed Ranch Scholarship—A scholarship will be given with preference to a
student planning a career in agronomy or other ag-related field.

Waukon Lions Club Scholarships – Two scholarships are given by the Lions Club.
Criteria are students pursuing career study in a health-related field. Preference will be
given to students who have demonstrated community service. Additional paperwork will
be required.

Waukon State Bank Scholarships – Two scholarships are awarded. Criteria include
scholarship, leadership, participation, and character.

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                              Allamakee Dollars for Scholars

Applicant Data
Name                                         Student ID #

Address                                      Date of Birth

City                                         Telephone No.

State                                        Parent/Guardian


College                                      Date starting
Planning to                                  program
Major/Field                                  Anticipated date
of Study                                     of completion

Place X in correct box
    community/jr. college
    voc/tech institution

Student will:        Student will be enrolled:
live on campus       Full time
live off campus      half-time or more
commute              less than half-time

  Related to an American Legion or American Legion Auxiliary member
Member’s name and relationship to you

Transcript information below will be completed by the Guidance Office.

Applicant ranks _____ in a class of ________.    Cumulative GPA _______

PSAT Verbal ______, Math ______;       ACT: English ______, Math ______

SAT Verbal ______, Math ______;

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Student ID #

Personal Data-1

Additional pages can be attached for Personal Data 1 & 2 pages.

Describe your work experience during the past 4 years. Indicate dates of employment in each job and
approximate number of hours worked each week. List total amounts earned at each job. Remember to
include all information or the section will be discard and points cannot be given.

        position           date from (mo/yr) to date (mo/yr)            hours/week        amount earned

Example: waitress at Town Cafe     June 2003 to June 2004               15 hrs./week      $3.00/hr. plus tips
       helped milk at home         June 2004 to Sept. 2004              30 hrs./week      $5.00/hr.

List all school activities in which you have participated during the past 4 years (e.g., student government,
music, sports, etc.). List all community/volunteer activities in which you have participated during the past 4
years. Indicate any offices, awards, or honors and the approximate time commitment involved.

        activity                   no. of years participated   special awards, honors, offices held

Example: student council           1 year (9th grade)          none
          4-H                      2 years (9-10th grades)     club secretary

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Student ID #
Personal Data-2
Make a brief statement of your plans as they relate to your educational and career objectives and future goals.

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. Explain how any
family or personal circumstances will affect your individual and family ability to finance your college

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Upon receiving a scholarship(s) from the Allamakee Dollars for Scholars organization at
Senior Honors Night in May, I hereby pledge to acknowledge this scholarship(s) with a
written "thank you" to the benefactor of my given scholarship(s). This applies to
Allamakee Dollars for Scholars awards and special scholarships given through Allamakee
Dollars for Scholars. This note will be written and turned in by graduation practice. It
should in a stamped envelope and addressed to the donor with your return address, all
ready for mailing.

I understand that this pledge is part of my Allamakee Dollars for Scholars application and
my scholarship(s) will be revoked if I fail to write this thank you note.

I have read and understand the application requirements given on page 1 of this
application. I agree that to be eligible for an Allamakee Dollars for Scholars award I
will meet all requirements.

__________________________                       ___________________________
Student Signature                                Parent/Guardian Signature

_______________                                  _______________
Date                                             Date

Date turned in & received by at
WHS Guidance Office

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                                            Applicant Appraisal

Name_________________________                                               Student ID #_____________

College/Major choice________________________________________________________
Please give the appraisal form to the evaluator you have selected. Remind the person of the due date of the end of
first semester and that they are to return the form to the WSH Guidance Office.

You have been asked to provide information in support of this application for Allamakee Dollars for Scholars. Please
give immediate and serious attention to the following statements. When complete, please return this form to the WHS
Guidance Office.

The applicant's choice of a post-       extremely             very          moderately        inappropriate
secondary education program is          appropriate           appropriate   appropriate

The applicant's achievements            extremely             very          moderately        not well
reflect his/her ability                 well                  well          well

The applicant's ability to set
realistic and attainable goals is       excellent             good          fair              poor

The quality of the applicant's
commitment to school and                 excellent            good          fair              poor
community is

The applicant is able to seek,           extremely            very          moderately        not
find, and use learning resources         well                 well          well              well

The applicant demonstrates               extremely            very          moderately        not
curiosity and initiative                 well                 well          well              well

The applicant demonstrates good
problem-solving skills, follows          extremely            very          moderately        not
through, and completes tasks             well                 well          well              well

The applicant's respect for
self and others is                       excellent            good          fair              poor

Signature of Reference Person____________________________ Date______________

You may choose to include a written recommendation in this space (and/or on the back of this sheet).
Additional comments are appreciated.


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