Application Form MHA Ronno Cook Memorial Scholarship Application Date* High School* Name (first, middle, last)* Date of Birth* Mailing Address* E-mail Father's Name (if applicant is under 21) Father's Address Father's Occupation & Employer Mother's Name (if applicant is under 21) Mother's Address Mother's Occupation & Employer Spouse's Name (if applicable) Spouse's Address Spouse's Occupation & Employer 1. Check any of the following who will contribute to your support in college: Parents Grandparents Stepparents Spouse Other If other, please list: 2. Types of financial aid for which you have applied or plan to apply: Scholarships Jobs on Campus Any aid which I am eligible Other If other, please list: 3. List any scholarships you have received. Indicate amount. 4. Explain any unusual circumstances that have affected your family’s ability to provide financial support for your college education. (only complete if under a parent’s care) Total pre-taxed income of custodial parent including child support (only complete if under a parent’s care): Number of dependents parents listed on income tax form last year: Number of siblings at home (and ages) Number (including you) to be in college next year: 5. Are you presently employed? Yes No Employer Hours per week Length of Employement List any other past work experience: 6. Is your spouse presently employed? Yes No Employer Hours per week Length of Employement List any other past work experience: 7. I plan to attend Western Piedmont Community College Fall 2017 Yes No What area(s) of study do you plan to pursue? High School GPA 8. List your extracurricular school activities and honors, talents, or hobbies. Attach an extra sheet if needed: File Upload: Upload 9. Describe any volunteer work in which you have been involved. Attach extra sheet if needed: File Upload: Upload 10. Attach at least 2 letters of reference from educators, employers, volunteer supervisors, or mentors. Reference #1* Upload Reference #2* Upload Reference #3 Upload Reference #4 Upload 11. Attach a 500-1000 word essay describing what secular humanism is and how it relates to your goals for the future (essay should be in Word format, 12 pt font, Calibri). Upload Submit
