The 2009-2010 Peierls Foundation Scholarship Application Checklist
To assist the Austin Community College staff in processing your scholarship application quickly and efficiently, check to be sure that you have completed the following items before turning in your application.
Have you answered all of the Personal and Financial Information questions?
Yes
No
Did you include your 200 word essay and sign at the bottom?
Yes
No
Has your instructor filled out and signed the Instructor Recommendation Form?
Yes
No
Do you live in one of the preferred zip codes? (78702, 78721, 78722, 78723) If no, did your instructor include a Justification for Zip Code?
Yes Yes
No No
Did you attach a copy of your GED certificate and transcript?
Yes
No
Have you included a copy of your valid Photo ID?
Yes
No
If your above answers are yes, then you are ready to mail or deliver your Peierls Scholarship Application to: Pat Culpepper Adult Education Program Highland Business Center Room 417.7 5930 Middle Fiskville Rd. Austin, TX 78752 Phone Number: 223-7729
Peierls Foundation GED Scholarship Criteria
The Peierls Foundation Scholarship Fund was established specifically for adult learners enrolled in Austin Community College’s Adult Education Program. Adults who receive their GED certificates through programs provided by Austin Community College or one of its community partners in the Travis County Adult Education Consortium are eligible to apply. Austin Community College reviews all applications, according to established criteria, selects and monitors scholarship recipients, and disburses funds as needed. Preference is given to east Austin residents. All awards will be made electronically within the college, and recipients will be notified of their awards by the ACC Foundation. Scholarship Applications are due May 1, 2009 for 2009-2010 School Year
Eligibility Criteria for the Peierls Scholarship:
1. The applicant must have completed instruction in the program, and earned their GED within one year of applying for this scholarship. 2. Applicant must present a valid photo ID to confirm eligibility. 3. Scholarship recipients must register for a degree or certificate program and may only take classes that count toward that program. 4. Scholarship recipients must enroll in and complete a minimum of 6 hours with a minimum 2.0 GPA each semester. 5. Students awarded a scholarship must enroll in the ACC Transition to College course, HUDE 0111, the first semester at ACC, in addition to the required 6 hours. 6. This scholarship is for use only at Austin Community College. 7. Scholarship recipients are required to attend a Peierls Orientation and to be tested on the TCOM. 8. Scholarship recipients must turn in a completed Progress Report on time to the Student Outreach Specialist each semester they are on scholarship. 9. Students awarded a scholarship must maintain contact with the Student Outreach Specialist every two weeks and also provide address or phone number changes. Inform Student Outreach Specialist before dropping a course or dropping out of school, or of any change of circumstances which would affect course load. 10. Scholarship recipients must write a thank you letter and complete the acceptance form before scholarship funds may be used. 11. Scholarship recipients authorize the scholarship donor and Austin Community College to use their name in media releases. By my signature, I agree to the following: To comply with the above outlined Scholarship Criteria. Authorize Austin Community College to release my progress and pertinent information to the Peierls Foundation. The information that I have submitted on this application is true to the best of my knowledge. ________________________________________ Signature _______________________ Date
The 2009-2010 Peierls Foundation Scholarship Application
Austin Community College Adult Education Program
____________________________________________________________________________________
Personal Information
Name: __________________________________________________________________________ Last First Middle
Address: _________________________________________________________________________ Number and Street Apartment # City State Zip Code
Phone Number: _____________________ Home
_____________________ Cell
_____________________ Work
E-mail Address ______________________________@_____________________
Social Security Number: ______________________ Marital Status: Single Divorced
Birth Date: ___________ Married
Male Separated
Female
Widowed
Note: The following question is optional and is used for statistical purposes only. Race/Ethnic Group Caucasian Black Hispanic American-Indian Asian Other Major at Austin Community College: _______________________________________ Associate Degree Certificate Transfer
Financial Information
*Complete each of the following sections with accuracy. The selection committee will consider the financial need of each applicant as an important factor in determining scholarship awardees. Current employer & Position_________________________________________ Hours per Week: ______ Monthly Salary: $ ____________ Yes No
If not employed, are you seeking employment? If yes, please complete the following:
Company/Type of Work: ___________________________________________ Hours per Week: ______ Monthly Salary: $ ____________
Are you receiving any additional funding/support? _________________________________________
Complete either Section A or Section B
Section A Dependent (You are supported by your parents) 1. Number of people in household (include yourself, parents, brothers, sisters) __________________ 2. Number in college: __________ 3. Parents current marital status: 4. Father's Annual Income: 5. Mother's Annual Income: 6. Applicant's Annual Income: Single
Below $10,000 Below $10,000 Below $10,000
Divorced
Separated
Married
$20,000-$40,000 $20,000-$40,000 $20,000-$40,000
Widowed
above $40,000 above $40,000 above $40,000
$10,000-$20,000 $10,000-$20,000 $10,000-$20,000
Section B Independent (You are no longer supported by your parents) 1. Number of people in household (include yourself, spouse, children…) 2. Number in college: __________ 3. Applicant's Annual Income: 4. Spouse's Annual Income:
Below $10,000 Below $10,000 $10,000-$20,000 $10,000-$20,000 $20,000-$40,000 $20,000-$40,000 above $40,000 above $40,000
__________________
Please complete using monthly income and expenses
Estimated Income (per month) Earnings of applicant Earnings of spouse Parent's contribution Savings Alimony Child Support Other resources (TANF, TRC, SSI) $________ $________ $________ $________ $________ $________ $________
Estimated Costs (per month) Rent Food Transportation Medical Child Care Other (Please List) _________________________ _________________________ Total Cost per Month $________ $________ $________ $________ $________ $________ $________ $________
Total Income per Month
$________
No
Do you receive housing assistance? Yes If yes, which type? Housing Authority
Section 8
Other
________________
Do you or anyone living with you (family member) receive any of the following? TANF Food Stamps Medicaid Unemployment Free/Reduced Lunch Social Security Benefits WIC Other Disability Workmen’s Comp VA assistance
Student Essay
Please type or neatly write a 200-word response to the questions below. Why are you applying for the scholarship? Briefly describe your financial need. What do you plan to study at ACC? What do you plan to do after you finish your time on the Peierls Scholarship?
________________________________________ Signature
_______________________ Date
Instructor Recommendation
Instructor’s Name: _______________________ Telephone Number: _______________________
Number of Hours for student: _____________________________
Average Attendance for last 6 months: __________________________
Please state your recommendation. If student is NOT an East Austin resident, please complete Letter of Justification for Zip Code. Recommendation
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
As the instructor, do you believe that this applicant will take at least 6 hours each semester, maintain a minimum GPA of 2.0 and comply with the other Peierls Scholarship requirements? _________________________________
Letter of Justification for Zip Code (Student lives in a zip code other than 78702, 78721, 78722, 78723)
Does the student have financial hardships? Please be aware that out-of-district students will have higher tuition & fees, and the scholarship may not cover the entire expense.
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
________________________________________ Instructor's Signature _______________________ Date