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Yom Sheini, 2 Tammuz 5777
Monday, June 26, 2017

The Kurt & Tessye Simon

Temple beth - el

Scholarship fund

Undergraduate application

THE KURT AND TESSYE SIMON

TEMPLE BETH-EL SCHOLARSHIP FUND

305 W. MADISON ST.

SOUTH BEND, IN 46601-1119

GENERAL INFORMATION CHECKLIST—UNDERGRADUATE APPLICATION

Dear Simon Scholarship applicant,

This package contains the forms you will need to submit in order to be considered for a Simon Scholarship. Please fill them out carefully, and make sure everything that is required is included in your application, including financial information and recommendation letters. As you fill them out, remember that the Scholarship Committee will consider the following when reviewing your application and deciding on whether you will be granted an award, as well as its amount: Academic performance; activities at Temple Beth-El; outside activities including employment; financial need; and recommendations. It is up to you to make the best case you can for your candidacy.

General Information:

A.    It is the applicant’s responsibility to prepare this material in folder form. Please avoid use of staples; use paper clips, if necessary, to keep pages together.

B.     Mail or deliver the application folder to the Scholarship Committee postmarked on or before March 15 prior to the start of academic year for which funds are sought.

Specific Data:

The following should be included in the application folder:

A.                Application with essay (pgs. 3-5)

B.                 Financial aid information: Complete the applicant’s budget form and have your parent or guardian complete the parental financial analysis. (See forms pgs. 6-7)  All financial aid          information will be kept confidential and will be seen only by Scholarship Committee members.

C.                 Two supporting letters of recommendation (See forms pgs. 8-9)

D.                Transcript of school record. Be sure the following are included:

  1. S.A.T. or A.C.T. scores
  2. Rank in class
  3. High school G.P.A.

THE KURT AND TESSYE SIMON

TEMPLE BETH-EL SCHOLARSHIP FUND

IMPORTANT:

Application must be filled out and postmarked on or before March 15 prior to the start of the academic year for which funds are sought.

Mail application to:

TEMPLE BETH-EL

305 W. MADISON ST.

SOUTH BEND, IN 46601-1119

Please print or type:

Today’s date: ___________________ Academic Year for which funds are sought: _______________

Name: ____________________________________________ 

Address: ____________________________________________________________________________

(Street, City, State, Zip)

Phone Number ___________________________________  Date of Birth: _______________________

Email Address                                                                                                                       

Signature of Applicant: __________________________________________________________________

Signature of Temple Member: (Must be in good standing for application to be considered)__________________________________________________________________________

Name of College or University you plan to attend this fall:

___________________________________________________________________________________

Degree sought and major: ______________________________________________________________

List the referees to whom you are giving the reference forms to be completed. The referees should be one teacher, administrator, or counselor, and one personal referee. Select your referees carefully.

Name: ________________________________________________  Phone # ______________________

Address: ____________________________________________________________________________

(Street, City, State, Zip)

Name: ________________________________________________  Phone # ______________________

Address: ____________________________________________________________________________

(Street, City, State, Zip)

Person financially responsible for your education:

Name :________________________________________________  Relationship: __________________

Other circumstances that you consider as having an important effect on family status:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name: _____________________________

1.      List high school activities by year.

2.      List community activities by year.

3.      List specific activities at Temple Beth-El or in the wider Jewish community (e.g. participation in meetings, volunteer work).

4.      List school, community, or Temple honors received.

5.      List work experience.

THE KURT AND TESSYE SIMON

TEMPLE BETH-EL SCHOLARSHIP FUND

Undergraduate Application

This essay must be typed or word processed with a maximum of 500 words on this sheet or on an attached sheet. The subject is, “What I hope to gain from my college experience.”

Signature: _________________________________________  Date: ________________

Name: _____________________________

APPLICANT’S BUDGET AND PARENTAL FINANCIAL ANALYSIS

  1. Applicant’s estimated budget
Expenses, School 1 Resources $
University tuition and fees $ Parental contribution $
Room and board $ Summer job earnings $
Books and supplies $ Expected school-year earnings $
Other $ University scholarships, grants $
TOTAL $ Other grant funds $
Expenses, School 2 Other income: $
University tuition and fees $ 1. Loans (estimated) $
Room and board $ 2. $
Books and supplies $ 3. $
Other $
TOTAL $ TOTAL $

1.            Total amount applicant has in savings, assets, and investments:

            ____________________________________

2.         Does applicant own an automobile?   Yes: __________     No: ___________

            If yes, Make: ________________     Year:____________ Value: _________

  1. Parental Financial Analysis (to be filled out by parent or guardian):

Father’s name: _____________________________________________ Age: _________

Occupation: _____________________________________________________________

Mother’s name: ____________________________________________ Age:  _________

Occupation: _____________________________________________________________

Parents’ marital status:

Mother: Single ________ Married _______ Widowed ________ Divorced ________

Father:    Single ________ Married _______ Widowed ________ Divorced ________

Family income (check appropriate range):

Under 25,000 ______             25,000 - 35,000 _______        35,000 - 45,000 ________

45,000 – 55,000 _______       55,000 – 65,000 _______        65,000 – 75,000 ________

75,000 – 85,000 _______       85,000 – 95,000 _______         Above 95,000 _________

Number of dependents:  __________________

Number of dependent children attending college: __________________

Any unusual medical or dental expenses not paid for by insurance?

_______________________________________________________________________

Value of investments (CD’s, stocks, bonds, etc.): ______________________________

Value of savings: __________________________

Any unusual circumstances (please explain): ________________________________________________________________________________________________________________________________________________

Signed by: ___________________________

                                                                                          (Parent or Legal Guardian)

                                    ___________________________

                                                                                        (Applicant)

___________________________

                                                                                         (Date)

           

Teacher/Administrator or Counselor Recommendation for the Kurt and Tessye Simon Temple Beth-El Scholarship Fund

Applicant Name __________________________________________________________________

   (Last)                                                (First)                                      (Middle)

Address: _________________________________________________________________________

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

Phone Number____________________________________ 

 

Please give this form, along with a stamped and addressed envelope to the person who will write in support of your application.

 

The Family Education Rights and Privacy Act of 1974 provides that you may waive your right to see recommendations. Please indicate by checking the appropriate phrase and signing your name whether or not you wish to waive this right.

I ____ waive ____ do not waive any right of access that I may have to recommendations that are submitted in conjunction with the Kurt and Tessye Simon Temple Beth-El Scholarship Fund.

Signature _____________________________

                               

We would appreciate a statement based on your knowledge and observations of this candidate that will help us in our task of selecting a scholarship winner. We would like comments on the applicant’s intellectual and personal promise. Most helpful are specific examples of the personal qualities and accomplishments that make this person unique. After the selection process, we will destroy all subjective evaluations of applicants. After completing the form, the recommender should give the recommendation to the applicant in a sealed envelope with his/her signature across the sealed flap, or you may send the recommendation directly to the Kurt and Tessye Simon Temple Beth-El Scholarship Fund, 305 W. Madison St., South Bend, IN 46601-1119.

This recommendation must be sent on or before March 15. You may use the back of this sheet or attached sheets.

Name (Printed) __________________________________________________________

Signature _____________________________Title _______________  Date _________

School _________________________________________________________________

            (Name)                                                (Address)                               (Phone)

Personal Recommendation for the Kurt and Tessye Simon Temple Beth-El Scholarship Fund

Applicant Name __________________________________________________________________

   (Last)                                                (First)                                      (Middle)

Address: ________________________________________________________________________

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

Phone Number____________________________________ 

Please give this form, along with a stamped and addressed envelope to the person who will write in support of your application.

The Family Education Rights and Privacy Act of 1974 provides that you may waive your right to see recommendations. Please indicate by checking the appropriate phrase and signing your name whether or not you wish to waive this right.

I ____ waive ____ do not waive any right of access that I may have to recommendations that are submitted in conjunction with the Kurt and Tessye Simon Temple Beth-El Scholarship Fund.

Signature _____________________________

                               

We would appreciate a statement based on your knowledge and observations of this candidate that will help us in our task of selecting a scholarship winner. We would like comments on the applicant’s intellectual and personal promise. Most helpful are specific examples of the personal qualities and accomplishments that make this person unique. After the selection process, we will destroy all subjective evaluations of applicants. After completing the form, the recommender should give the recommendation to the applicant in a sealed envelope with his/her signature across the sealed flap, or you may send the recommendation directly to the Kurt and Tessye Simon Temple Beth-El Scholarship Fund, 305 W. Madison St., South Bend, IN 46601-1119.

This recommendation must be sent on or before March 15. You may use the back of this sheet or attached sheets.

Name (Printed) __________________________________________________________

Signature ____________________________________________  Date ______________

_____________________________________________________________________

(Address)                                                                                           (Phone)

Upcoming Events

Jun
30

06.30.2017 5:30 pm - 6:30 pm

Jul
1

07.01.2017 10:30 am - 11:30 am

Jul
7

07.07.2017 5:30 pm - 6:30 pm

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8

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14

07.14.2017 5:30 pm - 6:30 pm