DEPARTMENT OF HUMAN RESOURCES
2008-2009 STAFF CHILDREN SCHOLARSHIP
PROGRAM
Please complete and return this
form to the Department of Human Resources by
*Also complete & submit a
form for children who may attend college in the following five years.
Student's Name:____________________________ S.S.
Number:____________
Is
this student the natural or legally adopted child of the
Was this student declared as an exemption on the most recent
Is the student under the age of 26?_ Yes ___ No Birthdate___________
College
to be attended,if known_________________________________________
Indicate: Semesters____ Trimesters____Quarters____
(circle 3 or 4 qtrs).
(available money is divided by the
number of semesters/quarters identified)
Year in college for 2008-09 (check
one):Freshman ____ Sophomore ____
Junior ____ Senior ____
Anticipated Graduation Date:_________
*Please list all dependents that will be eligible for college in the next 5 years next to the academic year they will be eligible to attend.
___________________________09-10___________________________12-13
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Employee's
Name:_____________________________________________________
Campus
Address: _____________________ Ext:________
Position/Dept: _____________________
Month/Year of Hire:___ /____
Full-time:___ Part-time:___
Employee's
Home Address______________________________________________
_______________________________________________
City State Zip
Employee's Home Phone: _________________
I understand
that I must submit a term bill and schedule to the Department of Human
Resources as soon as it is available. I agree to provide any information
required to verify the above information.
Sign______________________________________ Date_________