Lanetia Keeler Memorial Nursing Scholarship (f)

ENTRY FORM LANETIA KEELER MEMORIAL NURSING SCHOLARSHIP APPLICATION

STUDENT’S NAME: STUDENT’S HOME ADDRESS: City: Telephone:

State:

Zip Code: Social Security No.:

STUDENTS’S HIGH SCHOOL: Monroe High School 608-325-7118 th HIGH SCHOOL ADDRESS: 1600 26 Street, Monroe, WI 53566

College, university or other educational institution student plans to attend (Indicate name of school and address): First Choice: Second Choice:

Student’s Signature:

Date:

To Counselors: Please include the following: 1. ACT Composite Score 2. Copy of Transcript with GPA Counselors Signature:

Date:

The Scholarship will be paid on proof of enrollment in the second academic year.

I. Financial Need - In the space provided please indicate your family’s adjusted gross income from their last tax return: Under $15,000 $15,000 to $20,000 $20,000 to $25,000 $25,000 to $30,000

$30,000 to $35,000 $35,000 to $40,000 over $50,000

Total number of family members living at home: Number of dependants in your parents’ family including yourself: Children

Ages

No. Attending College

Other financial considerations which need to be noted:

II. Extracurricular Activities: Organizations and Clubs (Show years of involvement; also, please indicate any office held.)

Honors and Awards:

Community or Other Activities:

III. Work Activities: Are you now employed?

Yes

No

If yes, what type of work and how many hours per week?

Describe you other work activities (such as family farm, helping at home, family business):

In the space provided below, please describe in 75 words or less, in your own words and handwriting, why you want to be a recipient, the course of study or major field of interest you plan to follow, your proposed occupation or profession, and any other abilities you have that were not previously mentioned in this form.