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Common Scholarship Application

This is a sample of the common scholarship application for local scholarships. Do not use this form; the application is to be completed online. A link will soon be available. 

This form can be filled out electronically using Adobe Acrobat Reader Scholarships will be awarded to individuals whose permanent home address is in Florence / Dunes City or Mapleton / Swisshome /Deadwood and who are eligible to enroll in a trade school or an institution of higher learning. 

Applicant Information 
Last Name 
First Name 
Address 
City 
Zip  
Phone
Email Address
Date of Birth
Parent/Guardian Name 
Number of Siblings 
Have you applied to a college or vocational/tech program? Yes No If yes, where? _____________________________________________________________ If not, where do you plan to enroll? _________________________________________ What is your major or program of study? ____________________________________ Weighted GPA _________ Unweighted GPA__________ 
Class Rank____/_____ 
SAT composite______ M____R/W____ ACT composite_____ M____R____W____ 

Applicant Budget
Income
Have you applied for FAFSA? 
Savings for College: _________________ 
Family Contribution: _________________ 
Total Income: ___________ 
Expenditures 
Tuition Per Year: ____________________ 
Books and Fees Per Year: ____________
Room and Board: ___________________ 
Transportation: _____________________
Other Expenses: ____________________ 
Total Expenditures: ___________ 
Total Funds Needed: ________________ 

 This form can be filled out electronically using Adobe Acrobat Reader Supplemental Information 

Please address the following essay prompts using the provided blank pages. Multiple responses may be answered on the same page, although be sure to number each corresponding essay. Essays should be 250 word minimum. 

1. Begin with a summary of your post-secondary educational plans. Be specific in your planning and include where you plan to attend, what you plan to study, how you came to those conclusions and why going to college is important to you. 

2. College is expensive and getting more costly each year. Please explain any special circumstances that may make it challenging for you or your family to afford tuition expenses. 

3. What are you passionate about? What motivates you to do the best job possible? (volunteering, arts, athletics, family, etc.)

Please include a resume, activities chart, two (2) letters of reference and an unofficial transcript; either cut and paste into the additional pages of this form, or attach them when you email the form.

Also, select the scholarships you would like to apply for by using the Siuslaw Region High School Scholarships form and email it with your application. Note: An incomplete application will not be considered for scholarship eligibility. 

Submit this application by email to: smoser@siuslaw.k12.or.us. 

You can digitally sign this application using the fill and sign function in Adobe Acrobat Reader. 


DO NOT submit your application until you have included and reviewed all required information and signed the electronic signature. Certification Statement: I certify that the information on this application is true and correct to the best of my knowledge as of the date given.

 ___________________________________ _________________ Signature 

Date 

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