Jay-Sea Scholarship
Application
This scholarship was established in 2014 by Danielle Moser in honor of her parents Greg and
Marianne Moser who passed away in 2003.
Scholarship candidates should:
1. Be a graduating high school student from Jay County High School, Jay County, Indiana or
from a high school in King County, Washington
2. Have had at least one parent pass away
To the applicants regarding this scholarship application:
We ask that you be as accurate as possible knowing that any false or misleading information may
disqualify you for consideration. Please be assured that all information will be treated with the strictest
confidence.
All scholarship awards received must be used to cover the costs of tuition, required fees and books
only. Any misuse of funds will result in the repayment of all scholarship awards.
SCHOLARSHIP SELECTION PROCESS:
This is a donor advised scholarship held by The Portland Foundation. The donor will work with the
Portland Foundation Scholarship Committee with selecting the recipient. The Portland Foundation
Scholarship Committee is composed of members of the Portland Foundation Board of Trustees. The
committee reviews all applications turned in by the deadline.
To be considered for this scholarship, please complete the attached application and return it to The
Portland Foundation, 112 East Main Street, Portland, IN 47371, no later than:
February 25, 2016
JAY-SEA SCHOLARSHIP
APPLICATION
(Please type or print in ink)
1. STUDENT IDENTIFICATION INFORMATION:
Name_________________________________________________________________
(Last)
(First)
(MI)
Permanent Home Address___________________________________________
(Number, Street and Apartment Number)
___________________________________________
(City)
(State)
(Zip Code)
Telephone Number___________________________
Date of Birth________________________
Mark One:
_____ I am single
_____ I am married
_____ I am legally separated
2. HOUSEHOLD INFORMATION: (Information in this section should reflect information only
about where the student is living; that is, custodial parent).
With whom is the student living: Single parent, parent and step-parent, legal guardian etc. Please
indicate name and relationship to student.
________________________________________________________________________
Number of family members currently living in your household: __________
List names of brothers (B), sisters (S), step-brothers (SB), step-sisters (SS) currently living with you in
your home. Include name and relationship. If there is an adult child living at home but who works
outside of the home please indicate this by putting "WO" by their name.
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Number of college students in the household next school year: _____
Name
________________________
________________________
________________________
________________________
Year in school
____________
____________
____________
____________
1
School Attending
__________________
__________________
__________________
__________________
3. FINANCIAL NEED
Please provide explanation of financial need of assistance for education:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. STUDENT ACTIVITY
Name of university, college or technical school you plan to attend:
______________________________
School
______________________________
Location
Have you received official notification of acceptance? _______
If you have been accepted by a college or university, have you been notified that you will receive any
financial aid from that institution which will be applied toward your college expenses? _______ If
yes, please indicate amount __________
What is your intended major at this school? ____________________
This is a _____ 1 year _____ 2 year _____ 3 year _____ 4 year or longer program of study.
List all school and community activities in which you have participated and any honors which you
might have received.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2
During your high school years did you work during vacations, outside of school hours or during
summers? ______
If yes, during what years of school did you work? Please include work on family farm.
Dates during Number of
Employer
school year hours worked
per week
Dates during Number of
Employer
summer
hours worked
per week
Fr.
__________ __________
__________ __________
__________ __________
____________
____________
____________
__________
__________
__________
__________
__________
__________
__________
__________
__________
So.
__________ __________
__________ __________
__________ __________
____________
____________
____________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Jr.
__________ __________
__________ __________
__________ __________
____________
____________
____________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Sr.
__________ __________
__________ __________
__________ __________
____________
____________
____________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Will it be necessary for you to work while pursuing a higher education? _____
If yes, approximately how many hours do you anticipate working per week? ______
5. WRITTEN ESSAY
In no more than 500 words please submit a typewritten essay on a separate sheet that explains how the
loss of your parent/parents has influenced your development and future goals.
In submitting this application I certify that the information provided is complete and accurate to
the best of my knowledge. Falsification of information may result in termination of any
scholarship granted.
Applicant’s signature _________________________________________ Date __________________
Parent/Guardian signature _____________________________________ Date___________________
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