Scholarship application - 2009 - Print completed pages, attach photo, and mail by February 1, 2009 to the following address. Your high school must also send a transcript directly to this address by the due date.
   Scholarship Committee
   Polish Heritage Society of Rochester
   P.O. Box 273
   Webster, NY, 14580

A.  GENERAL INFORMATION

1. Name in full (Last, First, MI):

2. Home address (number, street, city/town, state, zip):

3. Telephone number including area code:

4. E-mail address

5. Name and address of high school currently attending:

6. List the college(s) you have applied to:

7. Describe the course of study you intend to pursue in college and why you made this choice:

8. Name and telephone number of your school advisor:

B.  PERSONAL INFORMATION

1.  Date of birth: 2.  Gender:

3.  Place of birth:

Language Write? Understand? Speak?

5.  School honors you have won: 

6.  School clubs and activities you have participated in:

7.  School sports you have participated in:

8.  Groups/organizations outside of school that you have  participated in and in what capacity:

9.  Hobbies and special interests and note any particular achievements and/or recognition:

10.  Names of other scholarships or financial assistance that you have applied for:

C.  STUDENT FINANCIAL INFORMATION

1.  Employment during the school year (places of work, hours/week, average weekly wages):

2.  Employment during the summer months when not in school (places of work, hours/week, average weekly wages):

3.  Estimate the amount of financial aid for college you will receive from your family each year while in college:

4.  Estimate the amount of funds you have saved for college:

5.  Estimate the yearly cost of tuition, lodging and food at the college of your choice:

D.  FAMILY INFORMATION

1.  Father’s name in full:

Birthplace: Living or deceased:
             City, State, Country

Occupation:Employer:

Address:

2.  Mother’s maiden name in full:

Birthplace:Living or deceased:
             City, State, Country

Occupation:Employer:

Address:

3.  Name of paternal grandfather:

Birthplace:Living or deceased:Occupation:
             City, State, Country

4.  Maiden name of paternal grandmother:

Birthplace:Living or deceased:Occupation:
             City, State, Country

5.  Name of maternal grandfather:

Birthplace:Living or deceased:Occupation:
             City, State, Country

6.  Maiden name of maternal grandmother:

Birthplace:Living or deceased:Occupation:
             City, State, Country

7.  If your parents are separated, with whom do you live?

8.  Which parent is of Polish extraction?

9.  How have you been involved in the Polish community (membership in organizations, participation in activities, etc.)?

10.  How have your parents been involved in the Polish community (membership in organizations, participation in activities, etc.)?

BE SURE THAT YOUR HIGH SCHOOL FORWARDS A COPY OF YOUR ACADEMIC TRANSCRIPT DIRECTLY TO US BEFORE THE APPLICATION DEADLINE.

E.  MY AUTOBIOGRAPHY

PLEASE TYPE a short autobiography in the space below.  Include any other information that would help the Scholarship Committee when reviewing your application.
ATTACH A RECENT PHOTOGRAPH OF YOURSELF.  PLEASE PAPER-CLIP IT TO THE APPLICATION.

I do so affirm that the above statements are true to the best of my knowledge and I understand that misrepresentation, now or in the future, will automatically disqualify me from scholarship benefits.

Signature:_______________________________________ Date:___________________