Madison County Homemakers
Love * Mentor * Support * Educate
  Udf Short Name  -  Madison County, AL     Alabama Homemakers  

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PERSONAL INFORMATION:

Student’s Name_________________________________________________________________
(First)(Last)(Middle)

Date of Birth_________________________________________________________________

Permanent Address ____________________________________________________________
(Street of Post Office Box)(City)(State)(Zip)

Mailing Address (if different from above)____________________________________________

Home Phone No. (    )__________________________________________________________

Parents: (Include titles such as Dr., Sgt., etc.  Indicate if deceased)

Father’s Name ________________________________________________________________

Mother’s Name ________________________________________________________________

Mother’s Occupation & Employer _______________________________________________

Name of Guardian, if other than parent _______________________________________

Number of brothers and sisters _______________________________________________

Do you have a parent or grandparent who is or was a member of a club affiliated with the Madison County Homemakers and Community Leaders, commonly known as Homemakers?  If yes, complete:

Name____________________________________________Where___________________________

Years of Membership, if possible________________________________________________

ACADEMIC INFORMATION:

Name of high school_____________________________________________________________

Address_________________________________________________________________________
(Street)(City)(State)(Zip)

Phone No. (          )_________________________________________________________

Principal’s Name________________________________________________________________

Counselor’s Name________________________________________________________________

HONORS AND ACTIVITIES:
Please list all of your activities, honors and leadership positions in high school, church and the community.


EMPLOYMENT HISTORY:
Employer_____________________________________Position Held______________________

Dates of Employment_____________________________________________________________
Employer_____________________________________Position Held______________________

Dates of Employment_____________________________________________________________

Employer_____________________________________Position Held______________________

Dates of Employment_____________________________________________________________

FINANCIAL REPORT:
                                  Occupation                      Total Amount of Income

Father _____________________________    ____________________________________

Mother _____________________________    ____________________________________

Applicant __________________________    ____________________________________

Please state the amount of financial assistance you will receive or expect to receive from parents or other relatives while in school.

Are there any extraordinary expenses in your family? (Illness, dependents, other family members in college, etc.) 

Have you applied for any other scholarship or financial aid? 

Source__________________________________________________________________________

Was aid granted?_________________________ Amount? ______________________________

CERTIFICATION:

I hereby certify that the data give above is true and accurate to the best of my knowledge.

Date____________________  Applicant____________________________________________

Date____________________  Parent/Guardian______________________________________

SHORT ANSWER:

1. Please describe your need for financial aid.

2. In what area are your interests with regards to a college major?

3. Why do you feel that you should be selected for a scholarship?

I authorize the release of the information provided on this scholarship application, ACT and SAT scores and high school grade point average to the Madison County Homemakers and Community Leaders committee and scholarship donors.

_________________________________________________  ____________________________
(Signature) (Date)

ALL OF THE ENCLOSED INFORMATION WILL BE CONSIDERED STRICTLY CONFIDENTIAL.

Updated: 11/25/2015 6:28:28 AM

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