Academic Scholarship Application

Applicant Information

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A) Personal

Applicant’s Name*

First Last

Permanent Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date of Birth*

Mobile Phone*

Email Address*

Marital Status*

Name of Spouse

First Last

Spouse’s Occupation

B) Family

Parent #1 Name

First Last

Home Address

Same as Applicant’s Permanent Home Address

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Email

Occupation

Parent #2 Name

First Last

Home Address

Same as Applicant’s Permanent Home Address

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Email

Occupation

Parents' Marital Status

If divorced, custodial parent?

Siblings

Name	Age	Occupation

Other Dependents

Name	Age	Occupation

C) Education

Current Enrollment Status for Upcoming Year*

Full-time student
Part-time student

Name Of College You Will Be Attending In The Upcoming Academic Year*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Expected Graduation Date*

Degree/Major Sought*

Grade Point Average Last Semester*

Please enter a number from 0 to 5.

If you have not yet attended, please enter 0

Cumulative Grade Point Average*

Please enter a number from 0 to 5.

If you have not yet attended, please enter 0

Academic Honors Received

Future Educational Goals

Previous Graduate School

Website

Dates Attended (start)

Dates Attended (finish)

Degree/Major Received

Previous Undergraduate School

Website

Dates Attended (start)

Dates Attended (end)

Degree Received

High School*

Town Located*

Website*

Dates Attended (start)*

Dates Attended (end)*

Other School

D) Employment History

Employment Status*

Current Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Employer(s)

Company	Address	Start Date	End Date	Position Held

E) Extracurricular Activities and Affiliations

Synagogue and/or Jewish Organizational Affiliations

Extracurricular and/or Volunteer Activities

Honors and/or Awards

F) Character References

Please provide names, addresses, and phone numbers of at least two people who know you well but that are not relatives.

Reference #1*

Name	Phone	Email Address

Reference #2*

Name	Phone	Email Address

G) Personal Statement

Provide a brief personal statement (500 words max) of your academic interests including your short and long term goals. Please write anonymously with no references to personally identifiable information.*

Financial Information

IMPORTANT NOTE: Documentation and verification of financial information will be required prior to the award of any scholarship assistance. If you are an independent student, as defined in Section J of this application, you will not need to document your parent's financial information.

H) Applicant and Family Income

Applicant Income*

Estimated Current Year’s Adjusted Gross Income	Actual Previous Year’s Adjusted Gross Income

Spouse Income

Estimated Current Year’s Adjusted Gross Income	Actual Previous Year’s Adjusted Gross Income

Parent 1 Income

Estimated Current Year’s Adjusted Gross Income	Actual Previous Year’s Adjusted Gross Income

Parent 2 Income

Estimated Current Year’s Adjusted Gross Income	Actual Previous Year’s Adjusted Gross Income

I) Financial Obligations

During the school year, which best describes your living situation?*

Live at home and commute
Live on campus
Rent an apartment
Own my own home

For you or your family's primary residence, do you own or rent?*

Own
Rent

Please indicate the approximate market value of the home*

Approximate monthly housing expenses (Please include total of Mortgage or Rent, Utilities):

List any other debts that you may have that affect your ability to afford your education:

Debt	Amount

Are there any other factors you would like the Foundation to consider in the assessment of you and/ or your family’s ability to finance your education?

J) Financial Independence

An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, or someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.

Are you financially independent from your parent?*

Yes
No

If you are not financially independent, parent's verification of income and signature are required.

K) Estimate of Expenses

Please provide a projection of your expenses for the upcoming academic year.

Tuition and Fees*

Room (Complete only if living in on- or off-campus housing that is separate from applicant’s permanent residence)

Board (Complete only if living in on- or off-campus housing that is separate from applicant’s permanent residence)

Books*

Clothing*

Recreation*

Medical Expenses*

Local Transportation*

Out of Town Travel*

Taxes on Employer Reimbursement for Graduate Programs

Other - Source(s)

Amount

Other - Source(s)

Amount

Total Expenses*

L) Sources of Financial Aid

For each source of financial aid listed below, please indicate the amount, secured or expected from each source. Figures entered in this section must demonstrate a realistic financial plan for addressing the educational costs listed in Section K above.

Applicant’s Personal Financial Contributions

Source(s)

Amount

Gifts from Family

Source(s)

Amount

Personal Loans from Family

Source(s)

Amount

Total Family Assistance

Federal Financial Aid (e.g. PELL)

Source(s)

Amount

State Financial Aid (e.g. TAP)

Source(s)

Amount

Total Federal & State Aid

Student Loans (e.g. PLUS, SLS)

Source(s)

Total Student Loans

EXTERNAL COMMUNITY SOURCES

There are scholarships and grants from external community sources that you or your family have available. This could include, but is not limited to: Foundations, religious, social, professional unions or other sources. Please indicate the sources and the total you anticipate receiving.

Source(s)

Total of all External Community Aid

Institutional Awards - Scholarships / Grants

Source(s)

Amount

Dedicated Program Aid - Opportunity Programs / Fellowships / Assistantships

Source(s)

Amount

Work Study / Campus Work Programs

Source(s)

Amount

Other

Source(s)

Amount

Total Campus-Based Assistance

Budget

Total Expenses

Family Assistance

Federal and State Aid

Lender Aid

External Community Aid

Campus-Based Assistance

Total Expenses – Total Reported Aid

Total Expenses – Reported Aid (Student Loans Excluded)

Amount of Specific Scholarship Assistance Requested, if applicable

Uploads (submitted as PDF or JPG)

Financial Aid Award Letter from your college/university. If you do not have this letter when you submit your application, please submit documentation of costs of attendance and details on how these costs will be met.
Verification of Income. Acceptable documents include individual/family tax returns (the first two pages of Form 1040 or the first three pages of Form 1040-SR), and/or W-2/1099 forms.
Academic Transcripts

File

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 50 MB.

Parent's Consent

I certify that this applicant is financially dependent and was claimed as a dependent on our most recently filed income tax return.

Parent's Consent

I hereby certify that the information provided in this application is true and correct.

Parent's Signature

Date*

Parent Name

Prefix First Middle Last Suffix

Applicant Consent*

I hereby certify that the information provided in this application is true and correct. Additionally, I attest that I am applying for all possible financial aid awards available to me as I pursue my academic program. I understand the importance of seeking out and maximizing all avenues of financial assistance to support my educational endeavors. By submitting this statement, I affirm my commitment to diligently explore and apply for scholarships, grants, loans, and other forms of financial aid to alleviate the financial burden associated with my education.

Applicant's Signature*

Date*

Applicant Information

A) Personal

B) Family

C) Education

D) Employment History

E) Extracurricular Activities and Affiliations

F) Character References

G) Personal Statement

Financial Information

H) Applicant and Family Income

I) Financial Obligations

J) Financial Independence

K) Estimate of Expenses

L) Sources of Financial Aid

Budget

Uploads (submitted as PDF or JPG)

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