ALTRUSA CLUB OF DAYTONRUTH RICHARDSON SCHOLARSHIP
2014 - 2015
Please type or print using black ink.
STUDENT INFORMATION
Name (First, MI, Last):
Date of Birth
Address:
Male
Female
Area CodeHome Phone:
City:
Zip:
Area CodeCell Phone:
Email Address:
Last 4 digits of SSN#
(required):
Ethnic and gender information is strictly voluntary and will be used only in reports to the Federal Government.
African-American
American Indian/Alaskan Native
Asian
Caucasian
Hawaiian/other Pacific Islander
Hispanic
Multiracial
Other
Father’s Name, Address, City, State, Zip:
Mother’s Name, Address, City, State, Zip:
Guardian’s Name, Address, City, State, Zip:
High School
GPA
ACT Composite
SAT CR
SAT Math
SAT Writing
COLLEGE INFORMATION
1st Choice
University Issued Student ID (if known):
2nd Choice
University Issued Student ID (if known):
Intended College Major:
FINANCIAL INFORMATION
Have you submitted a Financial Aid Form (FAFSA) and received the Student Aid Report (SAR)?
*If yes, what is the expected family contribution (EFC) as stated on the Student Aid Report (SAR)?
yes*
no
$
PLEASE READ THE CONDITIONS OF THIS AWARD ON THE REVERSE SIDE.
DUE DATE
IF THE REQUIREMENTS ARE NOT MET/COMPLETED, YOUR APPLICATION WILL NOT
BE PROCESSED.
ALTRUSA CLUB OF DAYTON-RUTH RICHARDSON SCHOLARSHIP
2014-2015
To be eligible for consideration, the applicant must:

Be a resident of Montgomery County, Ohio

Be a graduating senior of a high school in Montgomery County, Ohio

Demonstrate merit through past academic success with a 3.5 GPA or better (on a 4.0 scale).

Demonstrate financial need.

Submit an application accompanied by the following:
Letter of acceptance or other proof of acceptance/enrollment from the college or university
A copy of the summary page from the Student Aid Report (SAR) from the Free Application for Federal
Student Aid (FAFSA) – must show Expected Family Contribution (EFC)
A list of honors for scholastic achievement, awards, and co-curricular activities (athletics, debate,
dramatics, music, etc.) on a separate sheet and attach to this application.
7 semester official transcript
**************
If I am a recipient of scholarship funds, I must enroll on a full-time basis in an accredited post-secondary school or school
approved for Federal/State grants before funds are distributed.
My signature below indicates that I have read and understand the terms and conditions of this application, including but not
limited to the following requirements: resident of Montgomery County, enrolled as a senior in a participating high school, will
graduate from a participating high school located in Montgomery County, and have at least a 3.5 GPA out of a possible 4.0.
The Dayton-Montgomery County Scholarship Program, on behalf of Altrusa Club of Dayton, may use, transmit, receive or
request information from this form, my Free Application for Federal Student Aid, Pell Grant, Student Aid Report, award letters
from my college when required for admission, determining aid eligibility or referral. DMCSP may also request my high school
and college grade point average and/or transcript.
**************
We hereby certify that the information set forth in this application is true to the best of our knowledge.
Student Signature
Date
Parent/Guardian Signature
(If applicant under age of 18)
Date
If you are selected as a scholarship recipient, the Dayton-Montgomery County Scholarship Program
plans to publish your name and school in the newspaper.
If you do not want your name to appear, you must check this box: 
DUE DATE