Springfield Police Reserves Wagner Scholarship

Kickapoo High School

In order to apply for the Springfield Police Reserves Wagner Scholarship you must answer yes to the
following questions:

1. Are you a senior of Springfield Public Schools?
2. Are you planning to continue your education post high school?
3. Are you planning to pursue a career in the field of law enforcement or directly related to law
enforcement (juvenile officer, correctional officer or attorney)
*Please note preference could be given to an applicant whose parent is in law enforcement assuming all
other requirements are met. Other preferences that will be considered are scholastic ranking, good
citizenship, leadership, personality, integrity, dependability, initiative, perseverance and seriousness of
purpose and financial need, these should be addressed in your essay.

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*

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: *Type your name to sign your application.*

Date:*

MM/DD/YYYY Format

Parent/Guardian Signature: *Type parent/guardian 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 are receiving and the amounts of each scholarship.*

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

Please describe your goals for the future to show how your high school or work experiences have had an impact on you personally. Explain how you qualify for this specific scholarship. (3,000 character limit).*

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*

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