2011 Scholarship Application

Personal Information:
Name: (First)_______________________ (MI) _____ (Last) ___________________________
Street Address: _______________________________________________________________
City: __________________________________________ State: _____ Zip: _____________
Telephone: Home: ( ) _______________________
Work: ( ) _______________________
Cell: ( ) _______________________
E-Mail: _____________________________________________________________
Date of Birth: (mm/dd/yyyy) ___________________________________________
Parents Names:

(Father) ________________________________
(Mother) ________________________________

Parents address if different from above:______________________________________

This is ___ Mothers Address ____ Fathers Address
High School Attended: (Name, address and date of graduation)

______________________________________________________________________________
_____________________________________________________________________________

College or vocational school you will be attending: (Name, address and phone number)
______________________________________________________________________________
______________________________________________________________________________

Will you be entering as a __ Freshman __ Sophomore __ Junior __ Senior?

List all honors, extracurricular activities and organizations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Application Requirements. Submit the following:
1. Completed Application
2. Essay on how you aspire to incorporate the mission of Jane Doe No More into your education
and/or career following graduation. Jane Doe No More is dedicated to improving the way
society responds to victims of sexual assault so that all victims of this crime will have the chance
for a full and healthy recovery; thus shortening the time from crime to healing. (500 words or
less)
3. Two letters of reference:
one personal, non-family, reference
the other from a teacher, professor, social worker, victim advocate or other person involved
in carrying out a mission surrounding the issue of sexual assault who is familiar with you and
your education and/or career path.
4. Proof of academic standing (high school or college transcript)
5. List all additional loans, scholarships, and funding requested, list amount and organization. If
none, state none.
6 Proof of enrollment (College acceptance letter, current college transcript, etc.)
Failure to provide a complete application including all requested items will result in your
application being disqualified without review. Completed application should be returned to:
Jane Doe No More, Inc.
Scholarship Committee
Naugatuck Valley Community College
Kinney Hall Room 405
750 Chase Parkway
Waterbury, CT 06708