· Web viewApplication must be typed using this Microsoft Word document template. Please do not...

2 : 5/17/23 4 : document.dochf2

THE R. MADISON MITCHELL ENDOWMENT TRUST, INC.

THE R. MADISON MITCHELL ENDOWMENT TRUST, INC./LEO P. HEPPNER MEMORIAL SCHOLARSHIP APPLICATION


LEO P. HEPPNER MEMORIAL SCHOLARSHIP APPLICATION

INSTRUCTIONS TO STUDENTS FOR COMPLETING APPLICATION:

The Selection Committee makes its selection based solely on the information submitted on your application.

In preparing this statement, the applicant is to heed the following instructions below:

Provide as much information as possible. Winners are selected based solely on the information you provide.

Application must be typed using this Microsoft Word document template. Please do not exceed the space provided for each criterion. Please do not use a font size smaller than 11. To complete form, place cursor in gray box and the box will expand to allow the

text to fit. Some items have drop-down boxes with selection lists. Please pick the most

appropriate answer for these items. Please provide a student and a parent email address so that you can be contacted

should there be any questions about your application. Once the application is complete, please mail the application and the transcript

to: Bernie Bodt, 2917 Churchville Road, Churchville, MD 21028. The printed hardcopy will be submitted to the Selection Committee.

Please email the electronic file to: [email protected] This document does not need to have signatures.

Please keep in mind that the Selection Committee can only evaluate your application based on the information that you provide below. If it is not listed below, the Committee will not know about it.

Put your best effort towards persuading the Selection Committee to select you as a Leo P. Heppner Memorial Scholar.


mailto:[email protected]


PERSONAL INFORMATION STATEMENT

Name: (first) (middle) (last)

College Student Identification # (if known)

Preferred First Name:

**give form of your first name as you wish it to be printed in the banquet booklet, printed certificate, and banquet introductions (i.e. “Tom” for Thomas, “Becky” for Rebecca)

Home Address:

Date of Birth: Age:

Parents’ Names: Father:

Mother:

Legal Guardian (if different from parents listed above):

Home Telephone #:

Email Address: *needs to be valid after graduation

Parent’s Email Address:

Name of High School:

PLEASE PRINT AND SUBMIT ONE (1) HARD COPY OF THE COMPLETED APPLICATION AND MAIL TO:

Leo P. Heppner Scholarship Attn: Bernie Bodt2917 Churchville RoadChurchville, MD 21028

IN ADDITION TO THE HARD COPY PLEASE E-MAIL THE COMPLETED APPLICATION WITHOUT SIGNATURES TO:

[email protected]


mailto:[email protected]


PRIVACY STATEMENT, ACKNOWLEDGEMENT, RELEASE AND WAIVER

Federal law, including but not limited to, the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. §1232g; 34 CFR Part 99), and Maryland law, are laws that protect the privacy of student educational records. These laws apply to all schools that receive funds under an applicable program of the U.S. Department of Education and/or the Maryland State Department of Education. By your application to and participation in the Scholarship Program of the R. Madison Mitchell Endowment Trust, Inc./Leo P. Heppner Memorial Scholarship Application (the “Fund”), you will be required to disclose information to the Fund that is protected by Federal and State law. By your signature (if 18 years of age or older) or by the signature of your parent or legal guardian (if you are under the age of 18), you or your parent or legal guardian hereby give written permission to the Fund to release any information that you provide from your education records to the Fund for purposes, including but not limited to, the following: the Fund’s Selection Committee, the Fund’s website, local media including the Aegis newspaper, public announcement at the Fund’s annual banquet, photographs taken by the Fund’s official photographers, etc. You or your parent/guardian’s release shall remain in full force and effect unless revoked in writing and sent to the Fund via certified mail, return receipt requested. You or your parent/guardian hereby agree(s) to hold harmless and indemnify the Fund, its officers, directors, successors, and assigns from all liability in connection with the Release which is the subject of this paragraph.

__________________________________________ __________________Student Signature (if 18 or older) Date

__________________________________________ __________________Parent Signature (if student is under 18 years) Date

__________________________________________ __________________Parent Signature (if student is under 18 years) Date

__________________________________________ __________________Legal Guardian (if student is under 18 years) Date



CRITERION A: Academic Achievement

1. The applicant is asked to request his/her High School ACADEMIC TRANSCRIPT (MOST RECENT) be released to the Selection Committee. The transcript is to be attached to this form.

2. On a separate sheet of paper, list academic achievements, honors, and recognition, such as: school letters for academics, music, etc., honor roll, distinguished honor roll, scholar awards (Merit, Commended), student of the month, awards for art, drama, math, and science, perfect attendance, etc. Give class year where appropriate.

CRITERION B: Arts AchievementPlease list the school art programs you participated in during your high school career.

Art Noteworthy Achievements/Awards



CRITERION C: School Related Extra-Curricular ActivitiesState significant contributions to school life, including sports, student government, class offices, National Honor Societies, school publications, dances, plays, clubs, band, chorus, leadership, tutoring, etc. during your high school career.

List extracurricular activities and community

servicesRole played/

Leadership positions held# of

months

Approx. hours per month

CRITERION D: Propensity toward Service to OthersState significant contributions outside of school to community life, including membership in volunteer, recreation, church, and environmental groups and activities like scouting, 4-H, coaching, tutoring, walking/running in charity races, counseling, camps, visiting elderly, etc. during your high school career.

List organization or activity(NOT SCHOOL RELATED)

Role played /Leadership positions held

# of months

Approx. hours per month



CRITERION E: Essay -- Meaningfulness and Significance of Arts ParticipationThe applicant is asked to write a one page essay on the significance that arts participation has played in his/her personal growth and development.



CRITERION F: OtherThe winner is asked to address any remaining issues that he/she believes merit consideration by the Selection Committee, including but not limited to any special financial burdens or expenses of the family (Limit the response to Section F to one page in length.):

Employment: If you work part-time during the week, weekends, or during the summer, what do you do?

Future Education: If you know now, please state which school you will attend.

Intended Major: What is your current area of academic interest or concentration of studies and do you intend to pursue these in college? If you know, what are your career plans?


· Web viewApplication must be typed using this Microsoft Word document template. Please do not...

Documents

Transcript of · Web viewApplication must be typed using this Microsoft Word document template. Please do not...