Student’s DOB: ________
   
2016-2017
THE CULLEN SCHOLARS PROGRAM
APPLICATION CHECKLIST
To be considered, THE FOLLOWING ITEMS must BE SUBMITTED TO the BIsons children scholarship fund or edco IN THE ORDER LISTED BELOW BY january 29, 2016.
*All ITEMS MUST BE TYPED*
A completed 2016-2017 Application Form
Review of High School Entrance Exam Performance (9th Grade applicants only; nominating school completes)
Student Interest, Activities and Challenges
ESSAY: (For 9th grade applicants only; student completes) An opportunity for the Applicant to share his/her voice and tell the Selection Committee something about himself/herself.
LETTER OF RECOMMENDATION: One letter of recommendation from the nominating school on why they have selected the student for nomination of the Cullen Scholars Program.
A signed parent/guardian/student verification form
Most recent Report Card demonstrating B average or above (Please attach)
Verification of financial information (Please attach)
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Name of Nominating Personnel
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Signature
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Date
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Telephone Number
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Email Address
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2016-2017 CULLEN SCHOLARS APPLICATION
NOTE: STUDENT MAY ONLY BE NOMINATED BY ONE SCHOOL FOR SCHOLARSHIP
THIS PAGE IS TO BE COMPLETED BY THE NOMINATING SCHOOL – ALL APPLICANTS
Date:
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High School:
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4th or 8th Grade School:
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Private: Public: Charter:
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Does the student currently participate in Buffalo Prep? Yes No
Has the student ever received BISON Scholarship funding? Yes No
TOTAL GROSS HOUSEHOLD INCOME:
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$__________________
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Black or African American
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Number in Household:
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Asian
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Adults: _________
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Hispanic/Latino
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Children: _______
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American Indian
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Include source of verification of financial information:
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White
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Prior year’s tax form ______; OR
One pay stub from each contributing member of household ________
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Other (please specify)
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Student’s Class Grades
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Religion
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Reading
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Lang. Arts
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Math
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Soc. Studies
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Science
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Health
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Music
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Art
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For. Lang.
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AVERAGE
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Grade 4
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Grade 5
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Grade 6
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Grade 7
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Grade 8
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Accelerated Courses: Regents Math I Biology Earth Science Foreign Language
Provide any comments on grades, including any discrepancies:
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Entrance Exam:
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Attendance:
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Score
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Grade
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4
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5
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6
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7
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8
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Percentile (local)
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Days Absent
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What Exam
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Provide any comments on Entrance Exam Score and Days Absent:
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For Rising 9th graders: Ranking in School’s Freshman Applicant Pool:
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Top Third
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Middle Third
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Bottom Third
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REVIEW OF HIGH SCHOOL EXAM PERFORMANCE
THIS PAGE IS TO BE FILLED OUT BY THE NOMINATING SCHOOL
HIGH SCHOOL APPLICANTS ONLY
Provide information on high school academic exam given and student results: Please provide assessment of student’s academic ability and likelihood of success at your high school.
STUDENT ACTIVITIES, INTERESTS AND CHALLENGES
THIS PAGE IS TO BE FILLED OUT BY THE STUDENT
ALL APPLICANTS
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List any extracurricular activities you have participated in as part of elementary/middle school:
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List any activities you have participated in outside of school (i.e. community service, volunteering, church involvement, youth programs, and/or employment):
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Provide any additional information on specific challenges (academic or otherwise) you and/or your family may face as you prepare for middle school/high school:
STUDENT ESSAY
THIS PAGE IS TO BE COMPLETED BY THE STUDENT
HIGH SCHOOL APLLICANTS ONLY
In the space provided below, please TYPE your essay with a maximum of 250 words answering the following two-part question:
What life experiences have shaped who you are today? What challenges have you overcome in achieving your education (i.e. financial, personal, medical, etc.)?
Do not include your name on your essay; instead put your date of birth in the top right corner of this page. The essay must be written entirely by the student with no outside assistance.
LETTER OF RECOMMENDATION BY NOMINATING SCHOOL
THIS PAGE IS TO BE FILLED OUT BY THE NOMINATING SCHOOL
ALL APPLICANTS
Scholarship Purpose:
Cullen Scholars is a needs-based program that awards scholarships to a select group of Erie County students to attend private schools (grades 5-12) within The BISON Children’s Scholarship Fund and Education Collaborative of WNY (EdCo) networks.
The program is funded by the Cullen Foundation and operates in partnership with three education-based nonprofit organizations: the BISON Children’s Scholarship Fund; Buffalo Prep; and EdCo.
Instructions:
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Letters of Recommendations are to be completed and signed by the nominating school.
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Please tell us why you believe this student’s academic record and personal characteristics make him/her a strong candidate who will be successful at this school and as a recipient of this scholarship. Why should this student receive a Cullen Foundation Scholarship (motivation, special talents/gifts, financial or family circumstances)? In what way(s) would this student make a strong contribution to your particular school? If possible, please use letterhead.
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Include information on your association with this student including your name, title and signature.
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PLEASE DO NOT INCLUDE THE STUDENT’S NAME ANYWHERE IN YOUR LETTER. Each submitting school must black out all references to the candidate’s name on this recommendation and put the candidate’s date of birth on the top RIGHT corner of the letter of recommendation.
PARENT/GUARDIAN/STUDENT VERIFICATION
THIS PAGE IS TO BE FILLED OUT BY THE PARENT/GUARDIAN AND STUDENT
We hereby certify that all information provided herein is complete and accurate to the best of our knowledge. We understand that falsification of any information on this application will result in the termination of the scholarship.
Parent/ Guardian Name:
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Parent/Guardian Signature:
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Date:
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Parent/ Guardian Name:
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Parent/Guardian Signature:
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Date:
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Student’s Name:
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Student’s Signature:
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Date:
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Middle School/High School to which Applicant has accepted scholarship nomination:
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Applicant’s Date of Birth:
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How did you hear about the Cullen Scholars Program? |
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12/4/15 Page
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