Deer Valley High School



Antioch High School

Class of 2021

Scholarship Application

Student must be:

• A Graduating Senior

• Have a Minimum GPA of 3.0

Applications need to be submitted to the drop box outside the main office from January 25 -January 29, 2021 by 3pm.

Late applications will not be accepted.

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Scholarship Recipients must attend

Scholarship Night on Tuesday, May 11th, 2021 at 7:00 PM.

Required Documents:

← Signed and Dated Parent/Guardian Application (pages 3 & 7)

← Typed Personal Statement

← Attach a copy of income statements such as 1040 Federal Tax Return, Disability Statement, Social Security Statement, etc

← Approved Photograph

Deadline: February 7, 2020 at 4:00pm - Return application to the College and Career Center Applications will not be accepted after 4:00 p.m. on February 7th

Requirements: Minimum GPA requirement of 3.0

Must attend the Scholarship Night ceremony, Tuesday, May 12th at 7:00 pm

*Class of 2020 foreign exchange students are exempt from attending Scholarship Night.

This application will be stored at Antioch High School for review by the AHS Scholarship Committee and various community scholarship committees. Personal information is confidential and secure.

Please return this application to the drop box outside the main office.

All parts of the application must be completed.

Part I- Personal Information

Attach a current photograph of yourself (“2x3” full-face, non-selfie, placed inside photo box) (pg. 3)

Complete required information and consent signatures

Attach a copy of your current unofficial transcripts

Part II- Composite Sheet (pg. 4 & 5)

Complete all information, items 1 through 19

Part III- Personal Statement

Submit a typed personal statement at least one page long that addresses the following:

1. Future goals

2. Career plans

i. One of the following prompts:

A. What personal struggles have you endured that have made you a more resilient individual?

B. How will going to college help you give back to your community?

Avoid talking about other people as the personal statement should focus on you.

Staple your personal statement to this application.

Part IV- Financial Information (Optional)

Attach a copy of your 2019 Federal Income Tax 1040 form showing adjusted gross income.

Only completed applications will be considered for AHS scholarships.

PART I: PERSONAL INFORMATION

Last Name: _______________________ First Name:

Student ID#: __________________

Sex: M F Date of Birth:

Address:

City: ____________________ State: ZIP Code: _________

Telephone #: Email:

Academy: ___________________________ # of Years in the Academy: _____________

Academy: ___________________________ # of Years in the Academy: _____________

Attach Photo:

(Photo of student only, ie. school/graduation picture)

Due to the Student Rights and Privileges Act, it is necessary to have the following consent:

We hereby give consent to release scholarship information to those individuals who sponsor scholarships for students. We understand that all information given is subject to verification. We also understand if financial information is not included, the applicant will be excluded from consideration by any committee or donor who lists “financial need” as all or part of their selection criteria for a scholarship. We understand there are numerous scholarships which have “financial need” as a condition. We understand the applicant must attend the Scholarship Awards Night on Tuesday, May11th, 2021 if selected for an award.

Date: Applicant Signature:

Date: Parent/Guardian Signature:

PART II – COMPOSITE SHEET

Please answer all fields in its entirety for full consideration.

|Last Name |First Name |M.I. |

Demographic Information:

|Nationality |Racial/Ethnic Background(s) |Religion (if applicable) |

Financial Information:

|Total number of dependents/persons in household |Number of family members attending college full-time in Fall 2020 |

|Adjusted Gross Income |

Future Career, College, and College Major.

| | | |

|Career Plans |First Choice: |Second Choice: |

| | | |

|College Choice |First Choice: |Second Choice: |

| | | |

|College Major |First Choice: |Second Choice: |

Academic, Leadership, Awards, and Activities.

|List up to eight achievements, leadership positions, awards, or activities that occurred within the last 6 years. These may include but are not limited to |

|school, community or faith-related activities. |

|1. |5. |

|2. |6. |

|3. |7. |

|4. |8. |

AUSD Elementary and Middle Schools.

|List the Name of all the AUSD Elementary Schools you’ve Attended and the Number of Years Attended |

|Elementary School |Number of Years Attended |

| | |

| | |

| | |

| |

| |

|List the Name of all the AUSD Middle Schools you’ve Attended and the Number of Years Attended |

|Middle School |Number of Years Attended |

| | |

| | |

Community Memberships.

| |Yes |No |

|Have you (the student) been a member of Antioch Schools Federal Credit Union for at least 6 months? | | |

|Do you have a parent/guardian who is a member of the Antioch Schools Food Service Association? | | |

|Do you have a family member/guardian who is a member of the Antioch Woman’s Club? | | |

|Do you have a parent/guardian who is a member of the Antioch High PTSA? | | |

|Do you have a parent/ guardian who works in the AUSD as a classified/certificated employee? | | |

| If yes, What school? What is his/her position? | | |

| If yes, What school? What is his/her position? | | |

|Do you have an immediate family member (parent/guardian, grandparent, sibling, etc.) who has served in the U.S. Armed Services? | | |

| If yes, please complete the following |

|Relationship to You Branch of the Military |

|Relationship to You Branch of the Military |

|Relationship to You Branch of the Military |

Please Circle Each Club/Organization or Activity that you Have Participated in.

|ASAHI/ Makers |Pacific Islanders Club |Girls Code |

|CARE Club |Film Club |W.I.S.E. Conversations |

|Latinos Unidos |Panther Pantry |Interact |

|Dance |Hoop Dreams |Boxing Club (Feet First) |

|Key Club |LGBTQ |Black-Powerful-Educated (BPE) |

|Media Tech Club |School of Etiquette and Decorum |CSF |

|MESA |Manhood Development (SLC) |Cover to Cover |

|Buddy Club |Puente |Upward Bound |

|EAOP |Bring Change to Mind |Other: |

PART III – PERSONAL STATEMENT

What are your future goals and career plans? Answer one of the personal statement prompts:

* What struggles have you endured that has made you a more resilient individual?

*How will going to college help you give back to your community?

Attach your Typed Personal Statement!

Part IV- Financial Information

NOTE: Completion of the financial information is mandatory for those scholarships requiring “financial need”. If financial information is not included with the application or is incomplete, the student will automatically be excluded for consideration by the committee or donor who list financial need as all or part of their selection criteria.

___ Attach a copy of the front (first page) 2019 Federal Income Tax Form

___ I decline to disclose my financial information. Parent/Guardian: ________________________

(please sign)

2019 Income, Earnings and Benefits

1. The following 2019 U.S. income tax figures are from: (Please indicate with an X)

PARENT(S)/GUARDIAN STUDENT

A completed 2019 Federal Income Tax 1040 form

Reminder: Attach a copy of your first page

2019 Federal Income Tax 1040 form

(Showing adjusted gross income)

at the end of this application

• I understand that only applications that attach a financial statement will be considered for need-based scholarships.

• Student must attend the Scholarship Awards Night if selected for a scholarship.

Parent/Guardian Signature: _________________________________________

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FOR OFFICE USE ONLY:

Date Received: 3R Factor Score:

Deadline: January 25-January 29, 2021 at 3:00pm - Return application to the drop box outside the main office. Applications will not be accepted after 3:00 p.m. on January 29, 2021.

Requirements: Minimum GPA requirement of 3.0

Must attend the Scholarship Night ceremony, Tuesday, May 11th at 7:00 pm

*Class of 2021 foreign exchange students are exempt from attending Scholarship Night.

Attach photo in this box

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

For office use only:

Date Received: 3RFactor Score:

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