Date of Graduation from BHS:



2017 Application for Lomira Local Scholarships

Below is a list of local scholarships available for Lomira High School students. By completing this one form, you will be considered for all those for which you qualify. The full description of each scholarship is available in the counseling office. Both the application form and the reference form are available under the “Scholarship” link on the home page.

Erik Baxter Memorial Scholarship

“Be the Change” Lomira and Brownsville Lions

Service Scholarships

Bintzler-Waehler American Legion Scholarship

Bintzler-Waehler American Legion Auxiliary Scholarship

K.M. “Kitty” Braun Memorial Scholarship

Jerry Burmeister Memorial Scholarship

Alfons Dehring Memorial Scholarship

Kondex Corporation Scholarship

Dr. G.P. Langenfeld Memorial Scholarship

Lomira Area Chamber of Commerce Scholarship/Future Business Leaders of America

Lomira Area Chamber of Commerce Scholarship/Future Farmers of America

Lomira Senior Foundation Scholarship

Lomira Alumni Foundation Scholarship

Lomira H.S. Sports Booster Club Scholarship

Lomira Parents and Teachers for Children Scholarship

Dale Michels Family Endowed Scholarship

Gene Schroeder Scholarship

Theresa Lions Club Scholarship

Theresa Parent Teacher Club Scholarship

Theresa Parent Teacher Club “Delores Justman Theresa Elementary School Scholarship”

You will be considered on the basis of this application, your references and your transcripts. Please prepare the application carefully by typing or printing clearly in black or blue ink. Answer each question as completely as you can, not exceeding 150 words. Please be thoughtful and concise.

This application, including your references (two school-related and one non-school-related), and transcripts from Lomira High School (request from Ms. McDermott or Mrs. King in the HS office) must be submitted to the guidance office no later than 3:30 pm on Friday, March 10, 2017. Incomplete applications or those received after March 10, 2017 will not be considered. You must also complete the online version of the application and upload a copy of your essay. A recommendation request form is available online and should be utilized when requesting a school-related recommendation.

|GUIDANCE USE ONLY | |

|Date this application is submitted |      |

1. Personal Data

|A. |Name: |      |

|B. |Street Address: |      |

|C. |City, State ZIP: |      |

|D. |Phone: |      |

|E. |Email: |      |

|F. |Father/Guardian Name: |      |

|G. |Address: |      |

|H. |Phone: |      |

|I. |Mother/Guardian Name: |      |

|J. |Address: |      |

|K. |Phone: |      |

|L. |Father's Occupation: |      |

|M. |Employer: |      |

|N. |Mother's Occupation: |      |

|O. |Employer: |      |

|P. |Names & ages of other dependents in |      |

| |household | |

| |(Be sure to include other children in | |

| |college): | |

The following questions relate to the criteria of specific scholarships (please select only one answer for each question):

|Are you a citizen of the United States? |Yes No |

|What is your gender? |Male Female |

|What is your heritage? |African/American Caucasian |

| |Hispanic Other |

|Were you raised on an operating farm? |Yes No |

|Do you have a disability as defined by the WI Dept of Public Instruction? |Yes No |

|Have you participated in the special education program? |Yes No |

|Will you be a full or part time student at the post-secondary level in |Full-time Part-time |

|2017-2018? | |

|Are you or have you been a member of FBLA? |Yes No |

|Are you or have you participated in a bowling league? |Yes No |

| | |

| | |

| | |

|Are you a member of National Honor Society? |Yes No |

|Are you a member of FFA? |Yes No |

|Are either of your parent/guardian a member of the American Legion or Legion |Yes No |

|Auxiliary? | |

|Are any of your grandparents a member of the American Legion or Legion |Yes No |

|Auxiliary? | |

|Did you attend Theresa Elementary School? |Yes No |

|Did you attend Lomira Elementary School? |Yes No |

|Did you attend Lomira Middle School? |Yes No |

|Are you a child of a Theresa Lions Club member? |Yes No |

|Are you the child or grandchild of a veteran? |Yes No |

|What was your highest composite ACT score? | |

2. Education

Transcripts of all high school courses are required. Be certain to request these items early because applications submitted without transcripts will not be considered.

Schools attended if other than Lomira High School: Dates:

| |      |

3. List school/academic awards received.

|      |

4. Please complete the following chart in regards to the sports activities you have participated in. List only the sports in which you COMPLETED the entire season.

|Sport |Year and Level |Lettered? |Awards |Regional, Sectional, or State |

| |(i.e.Fresmen=F, Varsity=V) |(If so, please list years) | |Competition |

| |example:9F, 10 JV/V, etc. | | | |

| | | | | |

| | | | | |

| | | | | |

1. List major hobbies.

|      |

2. List major extra-curricular activities in and out of school, including length of participation and offices held.

|      |

4. Describe your work history beginning with most recent first.

|Employer |Job |Hours Per Week |Period Worked |

|      |      |     |      |

|      |      |     |      |

|      |      |     |      |

|      |      |     |      |

5. Describe your volunteer history during the last four years.

|Organization |Activity |Hours Per Week |Period Worked |

|      |      |     |      |

|      |      |     |      |

|      |      |     |      |

|      |      |     |      |

1. Please write a statement on the value of service and how it has impacted you personally.

|      |

2. Please explain how you have been able to “give back” to the Lomira Elementary and/or Middle School students.

|      |

3. What is your intended major and/or career? Why?

|      |

4. Where do you plan to go to college? Why?

|      |

5. What has your participation in extra-curriculars taught you that you can use in the future?

|      |

6. If you have participated in sports, please comment on why you are deserving of a Lomira Sports Booster Club scholarship and how the Booster Club have acted as a support system to the athletic program and your athletic career at LHS?

|      |

7. How do you plan to finance your education?

|      |

8. What do you anticipate will be your schooling costs for the coming year?

|Tuition |      |

|Room & Board |      |

|Books & Fees |      |

|Total: |      |

9. What is the basis for your estimate? Give the name and date of the college catalog or other source.

|      |

6. Have you been notified that you are to be awarded any other scholarships or grants? If so, please give name, date, and amount.

|      |

7. ESSAY: Please explain how your education at Lomira High School has taught you the importance of responsibility.

|      |

| |

| |

8. Please list the names, signatures, business telephone numbers, and e-mails of the three adults whom you are asking to complete reference forms for you. They must not be related to you and they must know you currently. Two must be school-related (at least one teacher). The third must be a non-school-related person (i.e., employer, minister). As a courtesy to your references, you are to provide each reference a copy of the form with an addressed, stamped (if necessary), standard business envelope. References can also fill out the form on-line ( click on the scholarship link). Please remind your references by word or telephone a few days before the application date. A missing reference could mean denial of a scholarship.

| |Name |Signature (if using online reference form) |Business Phone AND E-mail Address |

|Non-school-related |      | |      |

|School-related |      | |      |

|School-related |      | |      |

High school transcripts are required. If they are not included with your application, the application will not be considered. Requesting transcripts from the HS office is your responsibility and not that of the Guidance Department.

I certify that the information contained in this application is correct.

I further certify that I will attend LHS AWARDS NIGHT if I am notified that I have received a scholarship. FAILURE TO DO SO MAY RESULT IN THE FORFEITURE OF MY SCHOLARSHIP.

I also agree that, if I am awarded a scholarship and decide not to go on to school, I will notify the LHS guidance department in writing by AUGUST 1, 2017 at 1030 Fourth Street, Lomira, WI 53048. This will allow an alternate to be selected for a scholarship.

Student Signature: ______________________________________ Date:________________________

I am aware that if my son/daughter does not turn in this application before the deadline (Friday, March 10th, 2017 before 3:30 pm to the HS Guidance Department), the application will not be considered. I am also aware that my son/daughter has an obligation to attend LHS AWARDS NIGHT if they are informed that they are receiving a scholarship or they risk forfeiture of the scholarship.

Parent Signature:_______________________________________Date:__________________________

Please submit this form to the LHS Guidance Office at 1030 Fourth Street, Lomira, WI 53048 postmarked by no later than March 10, 2017.

Name of Applicant:      

The above named student has given your name to us as a reference for help in evaluating a scholarship application. Any insight based on your experience that would aid us in our consideration and help us to distinguish this applicant from others would be appreciated.

Please be specific and frank as possible, yet concise. You need NOT list the applicant's activities, grades or future plans. Those are reported in the application form. All information will be held in strictest confidence.

| |Below | |Above | | |

| |Average |Average |Average |Excellent |Outstanding |

|Scholarship | | | | | |

|Leadership | | | | | |

|Adaptability | | | | | |

|Initiative | | | | | |

|Reliability | | | | | |

|Integrity | | | | | |

|Self-discipline | | | | | |

How do you know the applicant? If teacher or coach, give the subject; if employer, the company. Please include length of time you have known the applicant and any additional comments.

|      |

Signature: _____________________________________________ Date      

Type Name:      

Place of Employment and Position Held:      

Business Telephone Number:     

Email:      

-----------------------

GUIDANCE USE ONLY

Class Rank: _______

GPA: HS ____________

Transcripts: HS _______

References: Non-school School School

Lomira Local Scholarship Reference Form

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