Charles Lyons Memorial Foundation Inc Scholarship Application

CHARLES LYONS MEMORIAL FOUNDATION, INC. SCHOLARSHIP APPLICATION

P.O. Box 236 • Lexington, Missouri 64067

Telephone 660-259-3150

For the 2015-2016 Academic Year

APPLICATION MUST BE ACCOMPANIED BY TRANSCRIPT OF SCHOOL RECORD

Personal data required of High School graduates who desire to attend college, technical, or trade school or pursue some other type of specialized education.

THE COMPLETED APPLICATION MUST BE RECEIVED ON OR BEFORE MARCH 6, 2015 at 5:00pm.

PLEASE TYPE OR PRINT THIS APPLICATION.

A PHOTO will be helpful because it will aid us in getting acquainted with you but it is not obligatory.

FULL NAME:

ADDRESS: Tel:

DATE AND PLACE OF BIRTH:

FATHER: AGE: OCCUPATION:

MOTHER: AGE: OCCUPATION:

Schools attended (Ninth Grade to Present):

Date will graduate Total Students in class Your Rank in class G.P.A.

What college or technical school do you plan to attend?

What is your intended major?

The undergraduate degree you will seek?

Positions held in gainful employment, periods of employment, average time employed each week, earnings, etc:

COLLEGE BOUND PERCENTILES / ACT SCORES / TEST DATE

What college or technical school do you plan to attend?

What is your intended major?

The undergraduate degree you will seek?

LEADERSHIP POSITIONS AND OFFICES:

List by name and by year (9, 10, 11, 12) leadership positions and offices held for school, church, community, and volunteer activities.

Example: Student Council President (12)

MEMBERSHIPS:

List by name and by year memberships and other participation for school, church, community and volunteer activities.

Example: Basketball (9, 10, 11)

HONORS AND AWARDS:

List by name and by year the honors and awards you have received for school, church, community and volunteer activities.

Example: Hospital Volunteer of the Year (1)

PERSONAL STATEMENT:

Write (type or print) a paragraph of 100 to 300 words, indicating your chosen field of college study. State your reasons for this choice. Include pertinent experiences, activities and accomplishments. Attach to final page of application.

Have you applied for scholarships or financial aid? If so, give details

Have you been granted Scholarship Aid? If so, give details

Do you intend to apply for Financial Aid at the college(s) you plan to attend? If so, give details

Are you in the A+ Program?

ESTIMATED EXPENSES FOR YOUR COLLEGE OR TECHNICAL SCHOOL YEAR

Tuition and Fees …………………………………………. $

Books and Supplies………………………………………. $

Board and Room…………………………………………. $

Commuting Expenses, if any ……………………………. $

Clothes …………………………………………………… $

Incidentals (haircuts, laundry, etc) ………………………. $

Recreation ……………………………………………….. $

Miscellaneous Expenses ………………………………… $

TOTAL ………….. $

YOUR ESTIMATED RESOURCES FOR THE COMING SCHOOL YEAR

Summer Savings ………………………………………… $

Other Savings and Assets ……………………………….. $

Contributed by Parents ………………………………….. $

Contributed by Relatives and Friends …………………… $

Loans from Parents ……………………………………… $

Any Other Loans ………………………………………… $

Part-time Job Earnings ………………………………....... $

Veterans Benefits of any kind …………………………… $

Scholarships ……………………………………………… $

Any Other Income or Resources …………………………. $

TOTAL …………... $

PARENTAL FINANCIAL ANALYSIS

Father’s Income Before Taxes …………………………………………………… $

Mother’s Income Before Taxes ………………………………………………….. $

Number Living in Household …………………………………………………….

Number of Family Members Attending College this fall ……………………….

Medical and Dental Expenses Not Paid by Insurance …………………………… $

Value of Investments (Stocks, Bonds, Life Insurance, Retirement) …………….. $

Any Additional Data or Unusual Circumstances to Show Financial Need and General Worthiness:

REFERENCES

For reference give the name, address and occupation of two persons you have contacted concerning your qualifications. Request that they provide a Letters of Recommendation to you in a sealed envelope which must accompany this application.

DATED:

FOR DELIVERY TO APPLICANT’S REFERENCE

RE:

The student above named has applied for a scholarship and/or assistance from the Charles Lyons Memorial Foundation.

You are requested to submit a letter expressing his or her general and specific qualifications as a college student.

Please enumerate any special circumstances you believe might be important in the final decision. Include character traits, integrity, leadership, outstanding attributes that make the student extraordinary.

Please submit your Letter of Reference to the student in a sealed envelope as directed by the student.

FOR DELIVERY TO APPLICANT’S REFERENCE

RE:

The student above named has applied for a scholarship and/or assistance from the Charles Lyons Memorial Foundation.

You are requested to submit a letter expressing his or her general and specific qualifications as a college student.

Please enumerate any special circumstances you believe might be important in the final decision. Include character traits, integrity, leadership, outstanding attributes that make the student extraordinary.

Please submit your Letter of Reference to the student in a sealed envelope as directed by the student.