Student Name: ____________________________________________________________

Social Security Number: _____________________________________________________

Home Phone Number:  ______________________________________________________

E-mail Address: ___________________________________________________________

Home Mailing Address: _____________________________________________________

                                    ______________________________________________________

High School Attended:  ______________________________________________________

Graduation Date: ___________________________________________________________
 

Please answer the following questions by circling the appropriate answer.

1)      Are you a recipient of a DACC Presidential Scholarship?

        Yes               No

(If yes, you may skip questions 2-4.)

In order to qualify for the Scholars Program, you must be able to answer yes to two of the following three questions.

2)     Was your grade point average in the top 20 percent of your graduating class?

        Yes               No

3)     Did you have a cumulative grade point average of at least 4.5 (3.5 on a four point scale)?

        Yes               No

4)     Did you have an ACT composite score of at least 25 or an SAT score of at least 1100?

        Yes               No
 

Please answer the following questions. You may use extra paper if necessary.

1) Please list your academic and personal accomplishments to date. (Scholarly awards, prizes, clubs, organizations, etc.)

[More on the back, please.]
 

2) Please list the names of two of your high school instructors who might serve as a reference:

        Name of Instructor: ____________________________________

        Place of Employment: ____________________________________

        Work Phone: ____________________________________

        Name of Instructor: ____________________________________

        Place of Employment: ____________________________________

        Work Phone: ____________________________________

3) What are your plans for your education?

4) What are your current interests or hobbies?
 

By signing this document, I, the candidate for the Scholars Program, am asserting that the information contained herein is factually true, to the best of my knowledge.
In addition, this signature constitutes my pledge to abide by the policies and requirements of the DACC Scholars Program and to make every effort to succesfully complete these requirements prior to graduation.  I further understand that failure to complete all the Scholars Program requirements will preclude me receiving any recognition for having participated in this program.

Student Signature: ________________________________________________ Date: ______________

Director of Scholars Programs: ______________________________________ Date: _______________

Date Application Received: _____________________
 
 
 

Please print this form, fill it out, and return it to the following address:

Lori Garrett, Director of Scholars Programs
Danville Area Community College
MMC
2000 East Main Street
Danville, IL 61832
 
 
 
 

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