For academic year 20____

Check one:

Freshman [   ]   Sophomore [   ]

Junior [   ]  Senior [   ]  Graduate studies [   ]

Current transcript must be submitted along with completed application form by May 1st.

1. Name ________________________________________

2. Age________

3. Home address _______________________________________

4. Home phone# ( _____) _______ - __________

5. Parent's/Guardian's full name ____________________________________

6. Father's occupation _____________________________

7. Mother's occupation _____________________________

8. Name of college you plan to attend _______________________________________

9. State total number of years you plan to attend college ______

10. Mailing address of college:

11.      A. Is this your first application? [   ] Yes [   ] No

          C. How much aid have you received so far from Rollstone Church? $__________

12.     A. What is your major subject? ___________________________________________

         B. What is your ultimate goal? _____________________________________________

____________________________________________________________________________

 

13.      A. List assets you have or hope to have on hand to finance this year's educational cost.

Savings $ _____________

Scholarships $ _____________

Awards $ _____________

Loans $ _____________

Earnings $ _____________

Other $ _____________

      B. How much financial assistance do you anticipate receiving from parent/s or any other

Total assets …………………………………………………… $ ____________

14. Please itemize the full cost of your education for this coming year.

Tuition $__________________

Room/Board (Dorm} $__________________

Books $___________________

Fees $___________________

Total cost …………………………………………………… $ ___________________

15. How long have you been a member of Rollstone Church? _____________

15. Do you contribute financially to Rollstone Church? [   ] Yes [   ] No

17. Have you been involved in any activities of the church?

Please list them ____________________________________________________

__________________________________________________________________________

The Scholarship Fund of Rollstone Congregational Church, United Church of Christ, is renewed by gifts and/or contributions of members and friends. A contribution, at a time when you are financially solvent, would be greatly appreciated.

PARENT OR GUARDlAN'S SIGNATURE _________________________________________