SCHOLARSHIP FOR STUD ENTS WHO ARE HARD OF HEARING OR DEAF A c a d em i c Y e a r 20 1 7 2 0 1 8 Deadline May 1 2017 SCHOLARSHIP This is a 1 000 scholarship to cover tuition books and supplies Recipient may use the funds for any semester including summer during the awarded academic school year Support from Sertoma and Oticon Inc provides the funding for the scholarships QUALIFICATIONS Must have a minimum 40dB bilateral hearing loss as evidenced on audiogram by an SRT PTA of 40dB or greater in both ears Must be a citizen of the United States of America Must be pursuing a bachelor s degree on a full time basis at a college or university in the United States graduate degrees associates degrees community colleges and vocational programs do not qualify Must have a minimum cumulative 3 2 GPA on a 4 0 un weighted scale o High School senior Cumulative GPA is for grades 9 11 and first semester for grade 12 o College freshman Cumulative GPA is all of high school and first semester of college o College sophomore or higher Cumulative GPA for all college level semesters completed DEADLINES All scholarship applications and requested materials must be received at Sertoma headquarters by 4 00 pm st Central Standard Time on May 1 each year Faxes are not accepted If the deadline falls on a weekend the following Monday will be used as the deadline date REQUIRED MATERIALS The following items are required to complete the application process Application must be on the original form typed and signed 2 Two letters of Recommendation High School and or College transcript Transcript must be from school but does not have to be official The school name applicant s name and GPA must be printed on the transcript GPA stated on application must be verifiable from transcript Show conversion if GPA is documented on scale other than 4 0 College freshman must include high school and college transcripts Recent audiogram from a hearing health professional must not be any older than two years Hearing loss on application must be verifiable from audiogram One additional copy of the application and letters of recommendation The additional copy must blank out all references to the student s personal information including name address phone email and social security number Submit all materials in a single envelope in the order listed Any additional items or items received separately will be discarded Application materials are to be single sided Please do not use staples NOTIFICATION TO RECIPIENTS th Scholarship recipients will be notified by June 30 of each year We only notify recipients no notification means the student did not receive the scholarship We cannot send out lists of recipients to those who do not receive a scholarship MAILING ADDRESS Sertoma Headquarters Hard of Hearing or Deaf Scholarship Program 1912 E Meyer Blvd Kansas City MO 64132 Sertoma will acknowledge receipt of applications by e mail only If you would like notification include your email address on the application We will not notify or acknowledge receipt of application by phone Rev 06 16
SCHOLARSHIP FOR STUD ENTS WHO ARE HARD OF HEARING OR DEAF A c a d em i c Y e a r 20 1 7 2 0 1 8 Deadline May 1 2017 STUDENT INFORMATION First Name ______________________________ Last Name ____________________________________ Address _____________________________________________________________________________ City ______________________________________________ State ________ Zip __________________ Phone ________________________________ Email ________________________________________ Level of Hearing Loss SRT PTA SRT Left Ear _______dB Right Ear _________dB PTA Left Ear _______dB Right Ear _________dB If applicant has a cochlear implant please note CI in the above line COLLEGE OR UNIVERSITY INFORMATION School the student will be attending or is currently attending on a full time basis If you have not determined a school or your application is pending list your preferred school School Attending ______________________________________________________________________ Degree ______________________________________________________________________________ month year Date entered entering college or university ________ ________ month year Anticipated date of graduation ________ ________ Total credits required for degree ____________ Estimated total credits during the 2017 18 academic year and 2018 summer term s ___________________ Estimated cost of tuition fees books supplies for 2017 18 academic year ________________________ Cumulative GPA on an unweighted 4 0 scale as of completion of the Fall 2016 semester High School _____________ 4 0 Undergraduate _____________ 4 0 Please answer the following questions in the space provided attachments will be discarded and the application not considered for the scholarship HONORS AWARDS RECEIVED Rev 06 16
Key Club Distinguished Club Member (March 2014), State Instrumental Solo and Ensemble: Saxophone Ensemble 1* (April 2015), National Honor Society Membership (April 2015), Tennis Varsity Letter (Fall 2015), Key Club Distinguished Vice President (March 2016), Scholar Athlete (2015-2016), Certificate of Completion: NEWAHEC Health Careers Summer Camp (June 2016), Tennis Varsity Letter (Fall 2016), Scholar Athlete (2016-2017), Honor Roll (2013, 2014, 2015, 2016, 2017), State Instrumental Solo and Ensemble: Saxophone Ensemble 1* (April 2016), Met Key Club volunteer hours goal (2014, 2015, 2016, 2017), Wisconsin-Upper Michigan Key Club Michael Brukwicki Award (March 2017)
Bachelor of Science in Nursing
University of Wisconsin-Eau Claire
SCHOLARSHIP FOR STUDENTS WHO ARE HARD OF HEARING OR DEAF Academic Year 2017 2018 Deadline May 1 2017 Please answer the following questions in the space provided attachments will be discarded and the application not considered for the scholarship COMMUNITY VOLUNTEER ACTIVITIES INTERSCHOLASTIC ACTIVITIES EXTRACURRICULAR ACTIVITIES include jobs held Rev 06 16
Key Club: Served as Club Sophomore Representative, Club Vice President. Coordinated Teacher Potluck, Lose the Shoes Soccer Tournament, Divisional Service Day. Awards: Distinguished Club Member, Distinguished Club Vice President.
Band, Pep Band, and Jazz Ensemble: Instrumental Solo and Ensemble (‘14, ‘15, ‘16): Saxophone Ensemble Score: B1, A1*, A1*. Jazz Ensemble Score: C1, C1, B1. Alto Saxophone Solo Score: C2, B1, A2.
National Honor Society
Girls Varsity Tennis: Varsity Letter, Scholar Athlete.
Life Force: Educated younger students the dangers of drug, alcohol, and tobacco use.
Forever Young: Educated senior citizens from the community on how to use technology.
District Bulletin Editor for the Wisconsin-Upper Michigan Key Club District (March 2016-March 2017)
USSF Soccer Referee (April 2011-September 2014)
Slide Attendant at Appleton AmericInn Lodge & Suites (May 2013-Present)
NEWAHEC Summer Health Careers Camp (June 2016)
Unless CORE Committee Member: non-profit organization created by teachers and students in order to educate, inspire and fundraise for various types of cancer. (February 2011-Present)
TOPS Soccer: Played one-on-one soccer with special needs children. (27 hours), Summer Fun in the Park: Coordinated and ran various family activities for children at local park bi-weekly in summer. (28.5 hours), Darboy Kiwanis Chicken Fest: Sold tickets for a local Kiwanis summer family festival. (43.75 hours), Key Club UNICEF Halloween Party: Organized, set up, ran and cleaned up the Halloween Party for children in the community. All proceeds went towards UNICEF. (30.5 hours), Adopt-a-Family Christmas Party: Set up, ran and cleaned up the Christmas Party which benefited families in need during the Holiday season. (20.25 hours), Special Olympics Young Athletes: Helped out with various activities for children with special needs. (14 hours), Forever Young: Educated senior citizens from the community on how to use technology. (14 hours), Other Key Club events: Varies from PTO babysitting, fundraising, and helping other schools in the community. (235.75 hours)
SCHOLARSHIP FOR STUDENTS WHO ARE HARD OF HEARING OR DEAF Academic Year 2017 2018 Deadline May 1 2017 Please answer the following questions in the space provided attachments will be discarded and the application not considered for the scholarship PERSONAL STATEMENT 300 500 words Explain how this scholarship will help to achieve your goals By submitting this application I have given permission to Sertoma to use my name and relevant information in all forms of publications including but not limited to print and web based Signature ___________________________________________ Date ______________________ Rev 06 16