Kipper Dale Smart Scholarship

Central High School

In order to apply for the Kipper D. Smart Scholarship you must answer yes to the following questions:
1. Are you a senior at Central High School?
2. Are you planning to continue your education post high school?
3. Have you made a sincere effort in your scholastic endeavors?
4. Have you excelled in high school, despite a difficult and/or adverse situation? (this should be
addressed in your essay)
5. Are you an inspiration to fellow students helping them perform at a higher level?
6. Have you had significant involvement in extra-curricular activities?
If you answered no to any of these questions you are not eligible for this scholarship. If you answered
yes to each question you may proceed to the application.

Apply

"*" indicates required fields

Your School Name*

Name of Scholarship You Are Applying For*

PERSONAL INFORMATION

Student Name*

Applicant Email*

Enter Email Confirm Email

Cell Number*

Date of Birth*

MM/DD/YYYY Format (ex. 07/20/1995)

Street Address*

City, State*

Zip Code*

Student ID Number*

PARENT/GUARDIAN NAME(S)

Parent/Guardian Name(s)*

Parent/Guardian Cell Phone*

Parent/Guardian Email Address*

SIGNATURES

By signing this application, you are verifying the accuracy of your completed form.

Student Signature: *Your typed name below serves as your legal signature.*

Date:*

MM/DD/YYYY Format

Parent/Guardian Signature: **Your typed name below serves as your legal signature.*

Date:*

MM/DD/YYYY Format

ACADEMIC INFORMATION

Unweighted High School GPA*

ACT Composite Score

SAT Reading Score and SAT Math Score

COLLEGE/UNIVERSITY INFORMATION

Educational Institute You Plan to Attend In The Fall*

City/State of Institute:*

Have you applied?*

Have you been accepted?*

What do you plan to major in?*

Leadership & Extracurricular Activities: List leadership and extracurricular activities you were involved in throughout high school, starting with the most recent.*

Community Service: List any community service (include dates) that you have performed during high school, starting with the most recent.*

Work Experience: List jobs you have held during high school, starting with the most recent.*

Honors and Awards: List scholastic awards, extracurricular activity awards, or civic honors that you have received during high school, starting with the most recent.*

A+ And Other Scholarships Received: Including A+, please list any other financial aid including scholarships and grants that you know you'll be receiving and the amounts of each.*

PARENT FINANCIAL INFORMATION

Complete the financial section based on your most recent IRS 1040. If parents are divorced or separated, answer the questions for the parent in which you, the applicant, lived with the most in the past 12 months. If you have lived with both parents an equal number of days in the past 12 months, include the parent who provided the largest amount of support on your behalf. If that parent has remarried, the stepparent's information must be included. If the applicant has been living independently from the parent/guardian, please indicate this. If some of the questions below are not applicable, please enter N/A in the box.

Father's Name*

Age and Occupation*

Mother's Name*

Age and Occupation*

Stepfather's Name*

Age and Occupation*

Stepmother's Name*

Age and Occupation*

Custodial Parent's Marital Status As Of Today*

Number of people in family, not including parents, who will receive the majority of parental support this calendar year. Include dependent children and other individuals living in the household who receive more than half their support from parents or guardians.*

Name and age of dependents.*

Number of dependent children, including applicant, as defined above, attending college this calendar year and taking a minimum of 8 hours of college credit.*

Indicate the custodial parent(s)'s annual household income (before taxes) based on their most recent IRS 1040.*

Please share any significant financial barriers that may affect your ability to further your education. (1,000 character limit)*

STUDENT ESSAY

Your essay responses will differ slightly from one scholarship to another as you address each scholarship’s qualifications and explain why you are a strong candidate.

Describe your goals for the future and explain how your high school or work experiences have shaped you personally. Use this space to share why you are a strong candidate for this scholarship.*

References

Please tell us the names and email addresses of 2–3 teachers and/or coaches you’d like us to contact for a reference letter. Minimum of 2 required.

Reference 1*

Name of Reference 1

Reference 1 Email*

Reference 1 Phone*

Reference 2*

Name of Reference 2

Reference 2 Email*

Reference 2 Phone*

Reference 3*

Name of Reference 3

Reference 3 Email*

Reference 3 Phone*

Thank you for completing this application!

Please note - submissions may take 3-7 minutes to complete. Once complete, you'll see a note confirming the submission. Thank you!

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