Type of Scholarship

☐ Undergraduate     ☐ Graduate

Academic Year

☒ 2023-24  

A.  Applicant Information:

First Name

M.I.

     

Last Name

     

Permanent Address

     

P.O. Box/Suite

     

City

     

State

     

Zip Code

     

County

     

Email

     

Cell Phone

(     )      

Home Phone

(     )      

Date of Birth

   /    /    

CHS Grad Date

   /    /    

Final GPA or Rank

   

Are you employed?

☐ Yes  ☐ No

If “Yes,” where?

     

# Hours worked per week

     

Annual Income or Hourly Wage

     

B.  Family Information

Parent/Guardian/Spouse

Cell Phone

(     )      

Home Phone

(     )      

Place(s) of Employment

     

Family contribution toward your educational expenses

     

C.  Academic Information

School you are/will attend

     

School Address

     

P.O. Box/Suite

     

City

     

State

     

Zip Code

     

Academic Level

☐ Freshman   ☐ Sophomore   ☐ Junior   ☐ Senior   /   ☐ Graduate

Major/Field of Study

     

GPA (if currently enrolled)

     

Have you received a previous CCSF scholarship?

☐ Yes   ☐ No

If “Yes,” when and how much?

     

Have you received a scholarship from a non-CCS agency?

☐ Yes   ☐ No

If “Yes,” when and how much?

     

Will this be renewed this academic year?

☐ Yes   ☐ No

What will be your enrollment status?

☐ Full-time Student   ☐ Part-time Student

D.  Applicant Interests and Goals

On the following pages, please answer each of the (3) questions presented.  Your responses should be typed in 12 point font, double-spaced, and be no more than one page per response.

Applicant Interest and Goals – Question #1

Briefly write about your involvement in your community, school, work or another area that interests you. In addition, share something significant about your experience in that area.   

     

Applicant Interest and Goals – Question #2

How do you plan to finance this educational opportunity? (Please indicate by estimated percentage – parents, loans, scholarships, work.) Explain how this scholarship would help you financially.  

     

Applicant Interest and Goals – Question #3

What are your goals and hopes for the future? (Include how you decided on this path, how you plan to make a difference, and if someone in particular has influenced you along the way.)   

     

E.  Privacy Declaration

With my signature below, I am acknowledging any information provided in as part of my scholarship application to the Circleville City School Foundation (CCSF) will be used to evaluate my scholarship request.  Further, I authorize CCSF to use any information, EXCEPT FOR PERSONAL FINANCIAL INFORMATION, for publicity purposes, with the following additional exceptions:

     

Applicant Signature

Date of Signature

     

F.  Notification of Change in Plans

With my signature below, I am affirming I will notify CCSF immediately, in writing, of any change in my plans to attend the school designated in my application for the upcoming academic year.

Applicant Signature

Date of Signature

     

G.  Submitting Your Application

Completed applications (with supporting documents) must be submitted via email to ccsfapplications@circlevillecityschoolfoundation.org

B.H.  Budget Details/CCSF Approvals (Completed by CCSF)

This Make a Difference Scholarship Application has been reviewed by the Circleville City School Foundation Scholarship Committee.  

This application ☐ HAS   ☐ HAS NOT been approved.

Date of Approval

     

CCSF Scholarship Committee Chair Signature

Date of Signature

     

Date of Full Board Approval

CCSF Chair Signature

Date of Signature

     

CCSF Scholarship Application                                 of