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You must also submit two references with this application. One of the references for current students must be from a health care or basic sciences instructor. Please write legibly in black ink or type the application. Do not leave any questions blank.If a question does not apply to you, put N/A for “not applicable”. The neatness of your application will be evaluated.
Name of School and Degree:_______________________________________________________
Program:______________________________________________________________________
Student Name:_________________________________________________________________
Social Security Number:__________________________________________________________
Curriculum: ___________________________________________________________________
Expected Date of Graduation: ____________________________________________________
Address: ____________________________________________________________________
_____________________________________________________________________________
Date of Birth: ____________________ Sex: __________ Race: __________
Telephone Number: _________________(home)
_________________(work)
Marital Status: ____________________
Number of Dependents: _____________
Ages: ________________________________
High School and Date of Graduation: ______________________________________
Colleges Attended and Degrees Received:___________________________________
Employer’s Name: ______________________________________________
Monthly Gross Income: $________________
Employer’s Address: ____________________________________________
Telephone Number: _____________________
Spouse’s Employer: _____________________________________________
Monthly Gross Income: $________________
(COMPLETE THIS SECTION IF YOU ARE LIVING WITH YOUR PARENTS.)
Parents’ Name(s) and Address: ________________________________________________________
________________________________________________________
Names and Number of Dependents in Parents Household: ____________________
____________________
____________________
Mothers Occupation: ___________________________________________
Monthly Gross Income: $_________________
Fathers Occupation: ____________________________________________
Monthly Gross Income: $_________________
Expenses per Month Resources per Month Rent/Room/Mortgage $_______ Net Income (after deductions) $________ Utilities _________ Spouse’s Net income (after deductions) _________ Telephone _________ Parent’s Contribution _________ Transportation _________ Financial Aid _________ Food _________ Veteran’s Education _________ Insurance _________ Other: ___________ _________ Loan Payments _________ ___________ _________ Other: __________ _________ ___________ _________ $ $
Total
Total
CONFIDENTIAL
I am applying for a scholarship through the Giving Hand Foundation.
As a reference, you have my authorization to give the information requested below.
Students Name (Please print.)
____________________________________________
Curriculum___________________________________
Students Signature_____________________________
Date:_____________
How long have you known the applicant?
_______________________________________________
In what capacity? ____________________________________________________
___________________________________________________________________
___________________________________________________________________
Please check the phrase which best fits the person in each trait listed below:
| TRAIT | NOT OBSERVED | OUTSTANDING | EXCELLENT | GOOD | FAIR | POOR |
| School Performance | _________ | __________ | ________ | ____ | ___ | ____ |
| Work Performance | _________ | __________ | ________ | ____ | ___ | ____ |
| Initiative | _________ | __________ | ________ | ____ | ___ | ____ |
| Maturity of Judgment | _________ |
__________ |
________ | ____ | ___ | ____ |
| Interaction with Others | _________ | __________ | ________ | ____ | ___ | ____ |
| Seriousness of Purpose | _________ | __________ | ________ | ____ | ___ | ____ |
Further Comments: _______________________________________________________
_______________________________________________________________________
Reference Signature_______________________________________________________
Date____________________
Printed Name ___________________________________________________________
Address _______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Return to:The Giving Hand Foundation
1341-B Westgate Center Drive
Winston-Salem, NC 27103
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