Items marked with a are required for your application to be considered complete



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Section 1. Biographical Information

Please provide the following information so that the Association may learn more about you.



Items marked with a red starare required for your application to be considered complete.

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red starHow did you hear about us?




If other please enter here:




red starFirst Name




Middle Initial




red starLast Name




red starDate of Birth

/ /

red starGender




red starAddress




Apartment Number




red starCity




red starCounty

question mark
i.e., Montgomery, Smithfield (do not add the word County - this is NOT United States)

red starState




red starZip




red starTelephone

() -

red starEmail




red starWhat country were you born in?




red starAre you a US citizen and currently residing in the United States?

Yes No

If you were not born in the United States, what year did you or will you become a U.S. citizen?




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Section 2. Financial Information

All applicants must submit a copy of the front page of their parent/guardians 2010 individual federal tax return (1040, 1040A, 1040 EZ or 1099 SSA). If your parents were not required to file a tax return, include statement copies showing the amount of any government benefits, such as food stamps or Public Assistance documents. If Benefit Statements are sent in, they must include the benefit amount for the month or year.

The financial information you provide will be used only by the Horatio Alger Selection Committee to determine financial need. In order to answer the Adjusted Gross Income item below, please refer to your or your parent/guardians 2010 federal income tax return. If you are claimed as a dependent on your parent/guardian's federal tax return, the answer to this item is based on your parent/guardian's income.



Items marked with a red starare required for your application to be considered complete.

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red starAdjusted Gross Income

$ (Numbers only)
If you are a ward of the state or are in foster care, enter 0 (zero) on the income line above.

You indicated you are currently a ward of the state or independent. For verification purposes you must submit by mail a letter from the court or your high school confirming your current status as a ward of the state or independent. This information is required in order for your application to be complete. Fax and emails will not be accepted. Please mail this letter to: Horatio Alger Scholarship Programs, PO Box 4030, Iowa City, IA 52243-4030.

red starTotal number of people dependent on this annual income, including applicant

question mark
This number must be the minimum number of family members listed on your federal tax form.

red starFather/guardian occupation


If you are not in contact with one or both of your parents/guardians and do not know their occupation please list "no contact".

red starMother/guardian occupation


If you are not in contact with one or both of your parents/guardians and do not know their occupation please list "no contact".

Is one or more of your parent's self-employed? If yes, please tell us what type of business they run.




Is your parent/guardian currently receiving state or federal financial assistance?

Yes No question mark

If yes, check which aid programs

Free/Reduced Lunch
TANF
WIC
Section 8 Housing
Medicaid/Medicare
SSI
Disability payments
Food Stamps/EBT
Utility Assistance
State or Federal Health Insurance (e.g., MediCal)

Are you listed on your parent/guardian's tax form? If no, please explain why. question mark




red starList all of the individuals who live in your house full-time and their relationship to you.

  #1
  #2
  #3
  #4
  #5
  #6
  #7
  #8
  #9
#10

red starHas one or more of your parents been unemployed in the last 6-12 months?

Yes No

If yes, what was their occupation before becoming unemployed?




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Section 3. Extracurricular Activities, Community Service and Employment

List your principle activities and interests, both in and out of school, in the order of importance to you. Please use whole, rounded numbers without plus symbols for both the hours per week or weeks per year field.



Items marked with a red starare required for your application to be considered complete.

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Please click here if you have not participated in any community service activities.

Community Service

Grades

Hours per week

Weeks per year

Leadership position held

9

10

11

12

Example: Habitat for Humanity













7

12

Vice President

































































































Please click here if you have not participated in any school activities.

School Activity

Grades

Hours per week

Weeks per year

Leadership position held

9

10

11

12










Example: Band













7

12

Vice President

































































































Work/Employment

Indicate how many hours of paid employment you work per week during the summer

question mark(whole numbers only)

red starIndicate how many hours of paid employment you work per week during the school year

question mark(whole numbers only - enter 0 if you do not work during the school year.)

Please indicate your current job/employment position




red starWhat motivates you to work?




red starIf you do not work, please explain why.




College Readiness Programs

Does your school offer college preparatory programs (e.g., AVID, Gear UP, Upward Bound)? This does not include AP, Honors or IB classes.

Yes No

Do you participate in a college preparatory program at your high school? This does not include AP, Honors or IB Classes.

Yes No

List program you have participated in




How many years have you participated in this program?




Section 4. Adversity

Please briefly explain each adversity you mark in the space indicated. An explanation is required for each adversity you identify by marking yes. Please be specific in your answers below. You will have an opportunity to explain your answers in more depth at the end of this section.



Items marked with a red starare required for your application to be considered complete.

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1. Are you or have you been in foster care or a ward of the state?

Yes     No

If yes, at what age(s) and for how long?




Are you in foster care or a ward of the state right now?

Yes     No

2. Have you ever been homeless?

Yes     No

If yes, at what age(s) and for how long were you homeless?




3. Have you experienced the death, incarceration, or abandonment of a parent/guardian?
(Incarcerate: placed in prison. Abandonment: to cease contact and support)

Yes     No

If yes, please list the parent/guardian, cause of death, length of incarceration or abandonment, and your age at time.




4. Do you live in a household where alcohol or drugs are/were abused?

Yes     No

If yes, please explain the circumstances to the best of your ability and your age at the time.




5. Do you have a physical/mental disability or serious illness?

Yes     No

If yes, please describe your disability or illness.




6. Have you suffered from physical/mental abuse?

Yes     No

If yes, please describe your experience.




7. Do you have critical financial need?
(Income < $50,000 annually)

Yes     No

If yes, please explain.




Please describe any other adversities you have or are currently experiencing that are not listed above.




I have not experienced any of the listed or other adversities.




I authorize the individuals that I list under the Letter of Support section as Letter of Support writers to view and comment on my adversity essay and the adversities that I have checked, including details. I understand that the comments provided by the Letter of Support writers will not be shared with me and are intended for use by the Horatio Alger Association/Review Committee only. I furthermore understand that if I do not check this box that I will not be eligible for the Horatio Alger scholarships. red star

Please describe in detail the adversities you indicated above and explain how the adversities that you have experienced in your life have motivated you to pursue and complete a college degree. (100-300 words) red star




To be considered for the Horatio Alger Scholarship, your Letter of Support provider will need to review your adversities and personal statement. By selecting the option below to lock your adversity section you officially indicate your agreement and give your consent to these terms and conditions. If you are finished with this section, please click on the "Lock This Section" checkbox below. You will not be able to change this section once you submit this section if you have used this option.
Section 5. Personal Statements

Each of the following personal statements is required to complete the application. This section of the application allows you to reveal who you are in your own words including some of your future goals and aspirations. We hope to learn about your motivations and personal attributes that will contribute to your success. You must complete both essays in order for your application to be considered complete.



Items marked with a red starare required for your application to be considered complete.

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Explain your career goal(s) and the importance of a college education in attaining those goals. (50-350 words) red star

College you hope to attend:


You do not have to be accepted to this college.

Personal Mission Statement. The biographies of the members of the Horatio Alger Association offer you examples of people who have chosen to live their lives based on the principles of hard work, honesty, integrity, perseverance, and service to their community. They have also attained success in a variety of ways within the American free enterprise system.

Select and read several biographies of Horatio Alger Association Members. Choose a member and explain how you have applied the virtues exemplified in the member’s life story in your own life. Use real life examples from your own experience. (50-200 words) red star

Member for Essay:
Please make sure to use the appropriate identification of the Member you choose to write about in the essay. Please do not refer to the Member by first name but by salutation and last name. For example: Mr., Mrs., Dr., etc.
You must submit a Letter of Support as one of the required documents for your application. The individuals submitting letters of support on your behalf must send their letters to our office electronically through our application system.

Letters of Support will not be released to applicants. They are confidential and for use only by the Horatio Alger Association's selection committee.

You should enter the names and contact information for all providers. Only one letter is required, but you may submit up to two names to write letters on your behalf.



You must first complete your adversities section and LOCK it prior to working on your Letter of Support.

A Letter of Support Provider is an individual who will complete and submit a letter of support form on your behalf.



How the online letter of support process works:

  • Click the "Letter of Support Provider List" button above. (This button will only appear after you have completed and locked your adversities section.)

  • Insert the names and contact information of each Letter of Support Provider.

  • Once the Letter of Support Provider information is saved, an email will be sent to the online Letter of Support Provider with an access code and instructions on how to proceed with the online letter of support.

  • When the Letter of Support Provider submits the form to our office it will become part of your application.

  • You can view the status of your online letters of support each time you log into your application account.

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Section 6. Academic Information

Please complete the following information related to your high school and your senior year classes. We will ask your school to fill out all information related to your academic progress including GPA, test scores, honors classes and class rank through the Certification Form website.



You must complete BOTH the Academic Information section and Adversity section in order for your counselor to receive an email with instructions on how to complete your Certifications Form.

If you wish to change your Counselor's information and resend the request for your Certification Form, you may do so. However, once your certifications form has been received, you will no longer be able to edit your CEEB Code or High School Counselor's information.



Items marked with a red starare required for your application to be considered complete.

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red starCEEB Code

(Your school's SAT/ACT Code)
Valley High School
Consult your school for this code or use this link.

red starName of Your High School Counselor


Please include first and last name.

red starEmail Address of Your High School Counselor




Resend Certification Request Email

An email has not been sent as you have not completed all of the requirements.

Certification Form Received

No

red starAre you involved in student government through your school?

Yes No

Will you be the first person in your family to attend college?

Yes No

red starPlease list below all of the classes that you are enrolled in for your senior year of high school. Please separate each class by a comma and make sure to include if they are honors classes, AP classes or dual enrollment.



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