application
EDUCATION HIGH SCHOOL NAME AND ADDRESS
DATE OF GRADUATION
LIST ACADEMIC HONORS (include honor societies, honor awards and scholarship awards)
APTITUDE TESTS COMPOSITE SCORES
/
GPA
/
ACT:
SAT:
LIST STUDENT ACTIVITIES IN WHICH YOU PARTICIPATED
COLLEGE
n WILL ATTEND n CURRENTLY ATTENDING n PREVIOUSLY ATTENDED
DATE OF GRADUATION
/
COLLEGE MAILING ADDRESS
TOTAL CREDIT HOURS EARNED
MAJOR FIELD
MINOR FIELD
DEGREE(S) EARNING
LIST ACADEMIC HONORS (include honor societies, honor awards and scholarship awards)
LIST STUDENT ACTIVITIES IN WHICH YOU PARTICIPATED
WHY HAVE YOU CHOSEN A LIBERAL ARTS EDUCATION?
STATE BRIEFLY YOUR REASONS FOR GOING TO COLLEGE
HAVE YOU PREVIOUSLY RECEIVED A CAPERS SCHOLARSHIP
n Yes
n No
HAS ANY MEMBER OF YOUR FAMILY EVER RECEIVED A CAPERS SCHOLARSHIP
IF SO, GIVE RELATIONSHIP
n Yes
n
No
Enclose your most recent scholastic transcript (high school or college) Page 2
/
GPA
FINANCIAL INFORMATION SPECIAL NOTE TO APPLICANTS: Please include salaries, wages, investment income and the value of any housing, car, or other allowances as “income.”
Estimated college expenses for the next academic year ....................................................................... Total monetary scholarships and amounts you have been awarded for the next academic year .......... Your parents’ adjusted gross income last year ..................................................................................... Your parents’ estimated adjusted gross income this year..................................................................... If married, your spouse’s adjusted gross income last year ................................................................... If married, your spouse’s estimated adjusted gross income this year .................................................. Amount your parents will contributes to your college expenses ............................................................
$ $ $ $ $ $ $
___________ ___________ ___________ ___________ ___________ ___________ ___________
If your parents are divorced: Amount of monthly child support payments, if any ............................ $ ___________ Is either parent required to provide you with a college education? ....................n Yes n No If yes, please give details ____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Did you earn any money from part-time work during high school or college? .................n Yes n No If yes, please describe the type of work, approximate number of hours worked per week and the rate of pay: ____________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Will it be necessary for you to work during your college year? ........................................n Yes n No If yes, what arrangements have you made for such work? ___________________________ _________________________________________________________________________ _________________________________________________________________________
List the following college attendance information for dependent brothers and sisters still living at home: NAME
AGE
NAME OF COLLEGE
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
ATTENdING COLLEGE
n Currently n Currently n Currently n Currently n Currently
n Next Year n Next Year n Next Year n Next Year n Next Year
REFERENCES List the following information for three adults, not related to you who have known you for several years. NAME
AddRESS
OCCuPATION
1. ________________________
_______________________________________
_______________________
2._________________________
_______________________________________
_______________________
3 _________________________
_______________________________________
_______________________
Page 3
COLLEGES List the following information for college(s) for which this scholarship, if granted, will be applied. NAME OF COLLEGE
AddRESS
1. ________________________
________________________________________________________________
2._________________________
________________________________________________________________
3 _________________________
________________________________________________________________
SIGNATURE
I certify that the information on this application is true, complete and accurate to the best of my knowledge.
_____________________________
___________________________________________
Date of Application
Signature of Applicant
Return your completed application with photograph attached to: Secretary Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
Page 4
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by the principal or superintendent of your high school. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF HIGH SCHOOL RECORD NAME OF HIGH SCHOOL
HIGH SCHOOL MAILING ADDRESS
______________________________________________________ is applying for a Capers Scholarship for the (name of applicant)
next academic year. He/she attended this high school from _________________ to _______________ earning an average grade of ______________ . Please provide the following information: 1. Statement regarding this student’s academic ability __________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Statement regarding this student’s character and interests ____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Special honors received while in high school _______________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by a college faculty member who knows you well. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF COLLEGE RECORD NAME OF COLLEGE
COLLEGE MAILING ADDRESS
______________________________________________________ is applying for a Capers Scholarship for the (name of applicant)
next academic year. He/she attended this college from _________________ to
________________ earning an
average grade of ______________ and, if applicable, earned the degree of _______________________________ with a major in _________________________________________ . Please provide the following information: 1. Statement regarding this student’s academic ability __________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Statement regarding this student’s character and interests ____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Special honors received while at college __________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by the rector or other church authority and received by the Scholarship Committee on or before the first day of March. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF CHURCH MEMBERSHIP NAME OF CHURCH
CHURCH MAILING ADDRESS
______________________________________________________ is applying for a Charlotte Capers Scholarship (Name of Applicant)
for the next academic year. He/she has been a member of this church for
______ years.
Please provide the following information: 1. How active has applicant been in your church? _____________________________________________________ ___________________________________________________________________________________________ 2. List positions of leadership held by this applicant in your church:________________________________________ ___________________________________________________________________________________________ 3. Does the applicant need financial assistance?
n Yes n No n Don’t Know
4. Are parents able to assume full financial responsibility for the applicant’s education? n Yes 5. Does the applicant have unusual leadership ability?
n No n Don’t Know
n Yes n No n Don’t Know
If Yes, please explain: _________________________________________________________________________ 6. Do you know of any reason why this applicant should not be awarded a Charlotte Capers Scholarship?
n Yes n No n Don’t Know
If Yes, please explain: _____________________________________________
__________________________________________________________________________________________ 7. Check the income bracket of the parents:
n Under $25,000 n Under $65,000
n Under $35,000 n Under $75,000
n Under $50,000 n Over $75,000
If the parents are divorced, please explain whose income you have estimated above and furnish any other information relating to the financial situation of the applicant: _________________________ ___________________________________________________________________________________________ 8. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
DATE OF GRADUATION
LIST ACADEMIC HONORS (include honor societies, honor awards and scholarship awards)
APTITUDE TESTS COMPOSITE SCORES
/
GPA
/
ACT:
SAT:
LIST STUDENT ACTIVITIES IN WHICH YOU PARTICIPATED
COLLEGE
n WILL ATTEND n CURRENTLY ATTENDING n PREVIOUSLY ATTENDED
DATE OF GRADUATION
/
COLLEGE MAILING ADDRESS
TOTAL CREDIT HOURS EARNED
MAJOR FIELD
MINOR FIELD
DEGREE(S) EARNING
LIST ACADEMIC HONORS (include honor societies, honor awards and scholarship awards)
LIST STUDENT ACTIVITIES IN WHICH YOU PARTICIPATED
WHY HAVE YOU CHOSEN A LIBERAL ARTS EDUCATION?
STATE BRIEFLY YOUR REASONS FOR GOING TO COLLEGE
HAVE YOU PREVIOUSLY RECEIVED A CAPERS SCHOLARSHIP
n Yes
n No
HAS ANY MEMBER OF YOUR FAMILY EVER RECEIVED A CAPERS SCHOLARSHIP
IF SO, GIVE RELATIONSHIP
n Yes
n
No
Enclose your most recent scholastic transcript (high school or college) Page 2
/
GPA
FINANCIAL INFORMATION SPECIAL NOTE TO APPLICANTS: Please include salaries, wages, investment income and the value of any housing, car, or other allowances as “income.”
Estimated college expenses for the next academic year ....................................................................... Total monetary scholarships and amounts you have been awarded for the next academic year .......... Your parents’ adjusted gross income last year ..................................................................................... Your parents’ estimated adjusted gross income this year..................................................................... If married, your spouse’s adjusted gross income last year ................................................................... If married, your spouse’s estimated adjusted gross income this year .................................................. Amount your parents will contributes to your college expenses ............................................................
$ $ $ $ $ $ $
___________ ___________ ___________ ___________ ___________ ___________ ___________
If your parents are divorced: Amount of monthly child support payments, if any ............................ $ ___________ Is either parent required to provide you with a college education? ....................n Yes n No If yes, please give details ____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Did you earn any money from part-time work during high school or college? .................n Yes n No If yes, please describe the type of work, approximate number of hours worked per week and the rate of pay: ____________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Will it be necessary for you to work during your college year? ........................................n Yes n No If yes, what arrangements have you made for such work? ___________________________ _________________________________________________________________________ _________________________________________________________________________
List the following college attendance information for dependent brothers and sisters still living at home: NAME
AGE
NAME OF COLLEGE
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
__________________________
______
______________________________
ATTENdING COLLEGE
n Currently n Currently n Currently n Currently n Currently
n Next Year n Next Year n Next Year n Next Year n Next Year
REFERENCES List the following information for three adults, not related to you who have known you for several years. NAME
AddRESS
OCCuPATION
1. ________________________
_______________________________________
_______________________
2._________________________
_______________________________________
_______________________
3 _________________________
_______________________________________
_______________________
Page 3
COLLEGES List the following information for college(s) for which this scholarship, if granted, will be applied. NAME OF COLLEGE
AddRESS
1. ________________________
________________________________________________________________
2._________________________
________________________________________________________________
3 _________________________
________________________________________________________________
SIGNATURE
I certify that the information on this application is true, complete and accurate to the best of my knowledge.
_____________________________
___________________________________________
Date of Application
Signature of Applicant
Return your completed application with photograph attached to: Secretary Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
Page 4
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by the principal or superintendent of your high school. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF HIGH SCHOOL RECORD NAME OF HIGH SCHOOL
HIGH SCHOOL MAILING ADDRESS
______________________________________________________ is applying for a Capers Scholarship for the (name of applicant)
next academic year. He/she attended this high school from _________________ to _______________ earning an average grade of ______________ . Please provide the following information: 1. Statement regarding this student’s academic ability __________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Statement regarding this student’s character and interests ____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Special honors received while in high school _______________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by a college faculty member who knows you well. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF COLLEGE RECORD NAME OF COLLEGE
COLLEGE MAILING ADDRESS
______________________________________________________ is applying for a Capers Scholarship for the (name of applicant)
next academic year. He/she attended this college from _________________ to
________________ earning an
average grade of ______________ and, if applicable, earned the degree of _______________________________ with a major in _________________________________________ . Please provide the following information: 1. Statement regarding this student’s academic ability __________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Statement regarding this student’s character and interests ____________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Special honors received while at college __________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
The Charlotte Capers Scholarship (Confidential) NOTE: This form must be completed by the rector or other church authority and received by the Scholarship Committee on or before the first day of March. Please supply him/her with a stamped #10 envelope (4.25 x 9.5) addressed to: Secretary, Charlotte Capers Scholarship Committee P.O. Box 23107 Jackson, MS 39225-3107
STATEMENT OF CHURCH MEMBERSHIP NAME OF CHURCH
CHURCH MAILING ADDRESS
______________________________________________________ is applying for a Charlotte Capers Scholarship (Name of Applicant)
for the next academic year. He/she has been a member of this church for
______ years.
Please provide the following information: 1. How active has applicant been in your church? _____________________________________________________ ___________________________________________________________________________________________ 2. List positions of leadership held by this applicant in your church:________________________________________ ___________________________________________________________________________________________ 3. Does the applicant need financial assistance?
n Yes n No n Don’t Know
4. Are parents able to assume full financial responsibility for the applicant’s education? n Yes 5. Does the applicant have unusual leadership ability?
n No n Don’t Know
n Yes n No n Don’t Know
If Yes, please explain: _________________________________________________________________________ 6. Do you know of any reason why this applicant should not be awarded a Charlotte Capers Scholarship?
n Yes n No n Don’t Know
If Yes, please explain: _____________________________________________
__________________________________________________________________________________________ 7. Check the income bracket of the parents:
n Under $25,000 n Under $65,000
n Under $35,000 n Under $75,000
n Under $50,000 n Over $75,000
If the parents are divorced, please explain whose income you have estimated above and furnish any other information relating to the financial situation of the applicant: _________________________ ___________________________________________________________________________________________ 8. Use the following space (and the back, if necessary) for any additional remarks regarding the applicant. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________ Signature
_____________________________ Date
___________________________________________ Title
