The Richie Dunavant Scholarship of Hope

Application

In order to process your application, the Scholarship Committee needs the following information:

• The completed application (page 3).
• A copy of the prior semester’s high school or college official transcript.
• A copy of your parent or guardian’s prior year’s IRS tax return Form 1040 with all schedules.
• A letter of recommendation from a Guidance counselor.
• Letters of recommendation from two other individuals who personally know you.

Please complete the following:

Full Name of applicant_____________________________________ Date of birth__________________

Phone number_______________________________    E-mail address__________________________

Home address_______________________________________________________________________

                        (Street address)                                                (City)                    (State)  (Zip code)

Who in your life has been treated for any type of cancer? Self, Parent, Sibling.  Must circle at least one to qualify. 

College you are attending or to which you have been admitted:_______________________________________

(Submit a copy of acceptance letter)

Year (please check one)? ____Freshman ____Sophomore ____Junior ____Senior ____5^th year Senior

Your (intended) major__________________________________________________________________

Do you intend to work while a student? ____yes ____no

Have you served in the Armed Forces? ____yes ____no

If you have worked during the summer or school year or have served in the military, please provide specific information on a separate sheet.  Also please include information regarding any extracurricular activities you participate in while at school and any volunteer work. (Submit as an attachment to this application).

Please estimate your anticipated college expenses:

Tuition (for fall and spring semesters)…………………………………………………            $__________________

College-assessed student fees ..………………………………………………………            $__________________

Books and school supplies …………………………………………………………….            $________________­__

Room and board …………………………………………………………………………            $__________________

Total estimated expenses ………………………………………………            $__________________

Please provide any financial assistance for college:

Scholarships………………………………………………………………………………            $__________________

College assistance……………………………………………………………………….            $__________________

Church assistance……………………………………………………………………….            $__________________

Other sources (please specify the source) i.e. parent or loans ……………………            $__________________

Total estimated financial assistance……….…………………………            $__________________

Signed______________________________________________________Date:____________________

Applications are due by June 20^th for the full year or January 15^th for the second semester.

The Richie Dunavant Scholarship

Instructions for Applicants

Each year, the Board of Directors of the Halifax County Cancer Association reviews all applications and makes scholarship grants.  The only requirements for an applicant to receive a scholarship are:

1.                  The student must be a Halifax County resident

2.                  The student must have a “B” or 3.0 on a 4.0 scale for the previous semester.

3.                  The student must be enrolled full time in an undergraduate degree program.

4.                  The student must complete the application and return it with the required attachments (three letters of reference, a copy of the final grades from the prior semester, a copy of IRS Form 1040, and a description of extracurricular activities).  Please note: The Board of Directors prefers that the letters of reference, the grade transcript, the IRS Form 1040, and activity list accompany the application.  Please do NOT send each of these separately.

5.                  The student must be able to answer yes to the following: I am a cancer survivor, or a parent or sibling is a cancer survivor or has lost his/her battle with cancer.

The letters of reference should include one from a guidance counselor known personally by the applicant, who can confirm the abilities, character, and needs of the applicant.  The other two letters must be from a teacher/professor and a person who has known you for more than 2 years and is not a family member.

All of the above must be received by January 15^th in order for the student’s application to be considered for the spring semester or by June 20^th in order for the student’s application to be considered for the fall semester.

All grants are for one year only. If a grant is approved, the Director of the Halifax county Cancer Association will issue checks in two or three installments, depending on whether the school is on a semester or trimester system.  The second (and if applicable, third) installment will be made only if the student has a “B” average for the prior semester.  IMPORTANT:  The student MUST submit his or her grades for the prior semester in order to receive the next installment.

Scholarship grants are made on a “need” basis and the amount of the grant will depend on the financial need of the student.  Currently, grants are not made for applicants whose adjusted gross income (parents’ and student’s) exceeds $125,000.

The Richie Dunavant Scholarship of Hope Application is enclosed.  Please complete it, including all required attachments, and send it to:

The Richie Dunavant Scholarship of Hope

Scholarship Committee (Phone # 572-2714)

P.O. 875

South Boston, VA 24592

Since scholarship grants are made only on a one-year basis, the student must re-apply each year.  A student may be a recipient no more than twice.

The Richie Dunavant Scholarship of Hope

Application 2009

Please check the scholarship for which you are applying:

____New application                 ____Re-application

NOTE: List answers to # 6, 9, 10, 13, 14, 15, 16 and 17 on a separate sheet of paper (include name and date of birth on all attachments).

Please print clearly

1. Name (in full) __________________________________________________________
2. Permanent address_____________________________________________________

City______________________ State________ Zip___________

3. Home phone __________________________________
4. Date of birth ______ / ______ / ________

  (month)      (date)           (year)

5. Sex: (   )Male (   ) Female
6. Brief summary of activities in which you participate at your school and in your community.  (extracurricular activities, leadership positions, athletics, volunteer work, etc.)
7. Name of high school from which you will graduate or have graduated: __________________________________
8. Rank in class: _______ 
   Number of students in class: __________
9. Colleges to which you have applied.
10. Your vocational goal(s): _________________________________________________
11. Total gross income of parents (IRS 1040): __________________________________
12. Total Gross income of student (IRS 1040): _________________________________
13. Person’s dependant on your parent(s) or guardian(s) (name and age).
14. All other types of aid for which you are applying.
15. Amount of financial aid required and for how long.
16. Reasons for requesting financial aid (include unusual financial obligations/medical expenses).
17. Essay (250 word minimum) with personal statement of why you are seeking the scholarship, the impact cancer has made on your life, or anything else you wish the committee to know.

Signature of Applicant ________________________ Date: _________­______

Signature of Parent / Guardian _________________ Date: _______________

Awards are available only to Halifax County residences and cancer survivors or those with parents or siblings who are cancer survivors or have lost their battle with cancer.