OHIO JCI SENATE CHARITABLE AND EDUCATION FOUNDATION

October 2009

Attached is the application for the U.S. JCI Senate Foundation scholarship program. The U.S.
JCI Senate is made up of the life members of the U. S. Junior Chamber of Commerce (Jaycees)
and fifteen (15) $1,000 scholarships will be awarded this year.

This application will also be used for the Ohio JCI Senate Foundation scholarships. This year
we will have two (2) categories to choose from. They are:
Category 1 U.S. JCI Senate criteria (Academic based)
Category 2 Ohio JCI Senate criteria (Need based)

In Category 1 first place will receive $1,000 and second place will receive $500. In addition, first
and second place in Category 1 will be submitted to the U.S. JCI Senate competition.

In Category 2 there will be three selected. The first place, which is named the “Morgan Jones
Memorial Scholarship”, is awarded $1,000. Second place will receive $750 and third place will
receive $500.
,
Last year’s winners were: Category 1 - Cody Strahler from Waterford HS
Zachary L. Dunn from Allen East HS
Category 2 – Nicholas L. Manion from Northeastern HS
Rebecca Auck from Buckeye Central
Kimberly Renner from River View HS

Please note applicants may only submit in one (1) category. Please be sure to mark which
category you wish to have your application judged, by indicating your preference at the top of
Page 1 of the application.

Deadline for submitting applications is January 8, 2010. The state judging will be held by
month-end. If you have further questions, you can contact me at 740-622-2763 or
patrobinson1@roadrunner.com. We in the JCI Senate and also in the Jaycees are very proud
of our young leaders of today. They are the future of our country and the leadership of
tomorrow.

Thank you,

Pat Robinson
Pat Robinson
Ohio JCI Senate Chairperson

(H) 740-622-2763
E-mail – patrobinson1@roadrunner.com
 SERVICE TO HUMANITY IS THE BEST WORK OF LIFE

UNITED STATES JCI SENATE FOUNDATION

SCHOLARSHIP PROGRAM

This package contains information and directions for applying to the United States JCI Senate
Foundation Scholarship Program. Each year $1,000 grants will be awarded to high school seniors who
are U.S. citizens graduating from U.S. accredited schools, and plan to continue their education at
accredited post-secondary colleges, universities or vocational schools. The number of grants awarded
annually will be at the discretion of the United States JCI Senate Foundation. They must be used for
educational expenses in the first year of full-time study. Checks awarded will be made out in the name of
the recipient and the educational institution of their choice.

INSTRUCTIONS FOR APPLYING

Please read the following points carefully. Failure to comply may be cause for disqualification.

• All submissions must be typewritten or printed.

• Included in this application package are all the necessary forms.

• Supporting documentation of your choice may follow each page as appropriate.

• Reference letters are limited to five (5) with a maximum length of one (1) page each.

• Your name must be on the top of each sheet in the package, along with a page numbering
system that states “page __ of ____”.

• Deadline for submission postmarked is January 8, 2010

• Mail to : Pat Robinson

46663 TR 74
Coshocton, OH 43812

________________________
 Page 1 of _____
PLEASE SELECT ONLY ONE

Category 1 Category 2
US JCI Senate Ohio JCI Senate
(Academic based) (Need based)

UNITED STATES JCI SENATE FOUNDATION

I. SCHOLARSHIP APPLICATION
1. Name of applicant ___________________________________________ Date ____________
2. High school _____________________________________________________________________
3. Home street address ______________________________________________________________
City _______________________ State ____________ Zip _______ Phone ______________
4. Student’s e-mail address ___________________________________________________________
5. United States Citizen (check one) Yes _____ No _____

General Information

1. Father’s Name ________________________________________ Check if deceased ___________

2. Home address ________________________________________ Occupation _________________
3. Mother’s name ________________________________________ Check if deceased ___________
4. Home address ________________________________________ Occupation _________________
5. Do you have a Step-parent or Guardian other than your parents ? __________
6. If so, what is their name and address ? _______________________________________________
_____________________________________________________________________________

7. List in chronological order the names of your brothers, sisters or other persons dependent
upon your parents for support:

Name Age Relationship

________________________ ______ ____________________

________________________ ______ ____________________

________________________ ______ ____________________

________________________ ______ ____________________

________________________ ______ ____________________

College/University you plan to attend:

Name _____________________________________________________________

Address ____________________________________________________________

Have you been accepted ? YES ____ NO _____

If yes, attach copy of acceptance letter.
 Page 2 of _____

Applicant’s Financial Statement

The financial contribution of the applicant toward his own education is an important
consideration in awarding this scholarship. The committee does not wish to penalize
those students whose industry and careful planning have been a consideration in
planning college attendance.

INCOME :
1. Savings to date $ _________________

2. Expected summer earnings $ ________________

3. Expected contribution from parents $ _________________

4. Earnings from part-time work $ _________________

5. Money from other sources: $ _________________

Include gifts from friends, relatives,
Education insurance, loans, other
Scholarships, etc.

TOTAL ESTIMATED INCOME $ ________________

EXPENDITURES :

1. Tuition and incidental fees $ ________________

2. Board and room $ ________________

3. Books and supplies $ ________________

4. Clothing $ ________________

5. Incidental expense (travel, recreation) $ ________________

TOTAL ESTIMATED EXPENSES $ ________________

*******************************************
Explain any special personal family or financial situation you believe merits consideration:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Page 3 of _____
II. Leadership Positions and Offices
List by name and by year ( 9, 10, 11, 12) leadership positions and offices held, and the
approximate time commitment each month for school, church, community and volunteer
activities.

Example:
Student council President ( 12; 2.7 hours/month) ____________________________
Hospital volunteer ( 11, 12 ; 25 hours/month) ____________________________
Yearbook editor ( 12; 35 hours/month) ____________________________
Basketball captain ( 12; 5 hours/month) ____________________________

III. Memberships
List by name and by year memberships and other participation and the approximate time
commitment each month for school, church, community and volunteer activities.

Example:
Basketball (9, 10, 11; 35 hours/month)
Hospital volunteer (9, 10; 25 hours/month)
Cheerleader (11, 12; 20 hours/month)
4-H ( 9, 10, 11, 12; 8 hours/month)
____________________________
____________________________
____________________________
____________________________

IV. Honors and Awards

List by name and by year the honors and awards you have received during high school.

Example:
Hospital Volunteer of the Year (11) ____________________________
County 4-H Leader ( 11) ____________________________
Boys/Girls State (11) ____________________________
National Merit Scholar (12) ____________________________
National Honor Society (12) ____________________________

V. Employment
List the names and addresses of employers, including family business or self-employment.
Indicate whether part-time, summer, full-time, with the hours you worked.

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Page 4 of _____
VI. References
You may include up to five (5) letters of reference from educators, clergy, employers, and/or
community leaders.

VII. Transcript
A copy of your current high school transcript MUST be included.

VIII. Personal Statement

Write (type or print) a paragraph of 100 to 300 words, indicating your chosen field of college
study. State your reasons for this choice. Included pertinent experiences, activities and
accomplishments. This will be the final page of your application.

IX. Staple all sheets together, at the upper left hand corner.

X. School contact
Fill in the following information completely:

____________________________________________ name of high school

____________________________________________ address of high school

____________________________________________

____________________________________________ school principal’s name

XI. SEND TO:

U. S. JCI Senate Scholarship Foundation
(name and address given on cover sheet)

Page ______ of _____

(Last page of submittal)

PERSONAL STATEMENT
I certify that the facts contained in this scholarship application are true and
correct. The United States JCI Senate Foundation is hereby authorized to verify
any information contained in this application. I understand that any falsification or
misrepresentation will result in disqualification.

Applicant’s Signature ______________________________________ Date ___________