The Patricia Rauch Continuing Education Scholarship - 2014
Application Requirements:
1. Applicant must have been an LCC client for at least 6 months or a dependent of a
client. Anyone interested in furthering his or her education may apply.
2. Please complete a transcript release form available in your high school guidance office.
You only need to comply with this step if 1) You have attended high school in the past 5 years
AND 2) You have not attended any educational institution after high school. If you have
attended any other institution such as a technical college or a university, please send those
transcripts instead. We do not need the grade reports/transcripts to be official. A copy of any
school document showing your most recent grades or an unofficial transcript is encourage as
it eliminates any fees that may charged by the school in order to obtain an official transcript.
3. The two personal letters of recommendations, we require, should be from persons
other than your family members. Teachers, coaches, and employers are all great resources to
get these letters from. Make sure to allow them an ample amount of time to write the letters.
Send transcripts along with photocopies of two letters of recommendation, including a
photocopy of your photo, and your completed application by May 30, 2014 either
through the mail to Lake Country Caring, P.O. Box 591, Hartland, WI 53029 or electronically
to LakeCountryCaringScholarship@gmail.com.
NOTE: THIS APPLICATOIN FORMAT IS FOR THOSE WHO PLAN TO MAIL THEIR APPLICATION.
Please print and send to Lake Country Caring, P.O. Box 591, Hartland, WI 53029
If you are interested in submitting it electronically go to LakeCountryCaring.com and use the electronic
application available under the Continuing Education Link under the Clients Information tab.
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Basic Information:
Full Legal Name: First: _______________________ Middle: ______________________ Last:_________________________
Address: Street: _______________________________________________ City:_______________________ Zip:_____________
Date of Birth: ______/______/______
I am a (Circle/Underline One):
U.S. Citizen
U.S. National
Resident Alien
Contact Information:
Primary Phone Number: (________) _________-___________ E-mail Address: ___________________________
Circle/Underline Phone Type:
Cell
Work
Home
Best times to reach you at this number: __________________________________________________________________
Future Educational Plans:
Please check which educational path you intend on completing.
_______ Vocational/Technical (1 or 2 yr. program)
_________4 Year College or university
_______ Other (please explain _________________________________________________________________________)
Course of Study (Major) you plan to pursue: ________________________________________________________
Desired School (If Known): ____________________________________________________________________________
Schools Address: Street: __________________________________________ City:_________________________________
Have you been accepted by the above school? (Please Circle/Underline one):
Yes
No
Waiting on Decision
Haven’t Applied
Other School(s) of Interest (if applicable):
Have you been accepted by the above school? (Please Circle/Underline one):
Yes
No
Waiting on Decision
Haven’t Applied
_________________________________________________________________________________________________________________
Have you been accepted by the above school? (Please Circle/Underline one):
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Yes
No
Waiting on Decision
Haven’t Applied
Educational Financial Aid:
List other scholarships you have applied for: ________________________________________________________
List any scholarships or forms of financial aid you have or will be receiving at this time:
1. __________________________________________________________________ Amount: ________________________
2. __________________________________________________________________ Amount: ________________________
3. __________________________________________________________________ Amount: ________________________
4. __________________________________________________________________ Amount: ________________________
If you have not attended an educational institution in 5+ years please skip to page 6.
Education and Extracurricular History
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Previous Education:
High School Name: _____________________________________ City: ________________________ State: ______________
GPA: ___________ Composite ACT score (if taken): ________/36
SAT score (if taken): ___________/2,400
☐ Please check if you are presently attending here.
Higher Education Institution(s) (If applicable):
Name: ____________________________________________ City: ___________________________ State: _____________
Dates Attended: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you are presently attending here.
GPA: ______________________
Name: ____________________________________________ City: ___________________________ State: _____________
Dates Attended: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you are presently attending here.
GPA: ______________________
Extracurricular Activities
School activities may include sports and letters earned, student senate, music, drama, clubs, or any
extracurricular activities sponsored or sanctioned by you high school. On the lines below please
list school activity and describe responsibilities, offices held, and recognitions (e.g. letters earned,
membership in honor societies).
School Activity
a. ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Dates Involved:
___________/___________/______________ to ___________/___________/______________
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b. ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Dates Involved:
___________/___________/______________ to ___________/___________/______________
c. ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Dates Involved:
___________/___________/______________ to ___________/___________/______________
d. ______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Dates Involved:
___________/___________/______________ to ___________/___________/______________
List any additional awards or recognition you have received during the completion of education.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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Work History:
Please list the 3 most recent employers
1. Company Name: _______________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per week: _____________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently working here.
Reason for leaving (if not currently employed): __________________________________________________________
2. Company Name: _______________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per week: _____________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently working here.
Reason for leaving (if not currently employed): __________________________________________________________
3. Company Name: _______________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per week: _____________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently working here.
Reason for leaving (if not currently employed): __________________________________________________________
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Community Involvement
*Please list any volunteer involvement below. If not applicable please skip to page 8.*
1. Organization Name: ___________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per month: ___________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently volunteer here.
2. Organization Name: ___________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per month: ___________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently volunteer here.
3. Organization Name: ___________________________________ City: ___________________________ State: __________
Position Title: _______________________________________________ Hours per month: ___________________________
Job Responsibilities: _________________________________________________________________________________________
Dates Employed: ___________/___________/______________ to ___________/___________/______________
☐ Please check if you presently volunteer here.
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Personal Statement
Please use word processing for this section. Use and attach a separate sheet if you prefer. Other
criteria (grades, activities, etc.) being relatively equal, this statement is one of the determining
factors used by the selection committee. Correct spelling, grammar, and sentence construction
are important. This statement should include the following:
1. State your educational goals/objectives. Why?
2. Do you have a specific career choice in mind at this time? Give reasons for your choice,
or the reasons that you are undecided.
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3. Why should you be considered for The Patricia Rauch Continuing Education
Scholarship?
4. (Optional) Describe any special family circumstances which should be considered in
reviewing your application e.g. number of siblings in college, family situations such as
unemployment or large medical expenses, etc.
By signing below I acknowledge that all of the information above is correct to the best of my knowledge
and that Lake Country Caring may contact me regarding the scholarship.
Applicant’s Signature:
Signature _________________________________________________________
Date ____________/____________/_____________
Please provide the signature of parent or guardian if applicant is less than 18 years old.
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Signature _________________________________________________________
Date ____________/____________/_____________
Please send to Lake Country Caring, P.O. Box 591, Hartland, WI 53029
Remember to also send us your letter of recommendation via email or mail.
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