For Office Use only /

Date received
Application
No.
Received by

Lutheran Academy 2016/17 Scholarship Scheme

2016/17
Academic/Music/Arts/Sports Scholarship Application Checklist

Name:

Class (No.): ()

Date:

Students who plan to apply for an Academic/Music/Arts/Sports Scholarship Scholarship should

carefully check that they have gone through the following steps and submitted all documents listed
below. Should there by any missing documents, the application will not be considered.

I.

Completely filled in every single black on the Application Form.

II. Checked and confirmed whether the applicant meets the requirements.

III. Provided Progress Report by:

1.
2015/16 1st Semester Progress Report copy
2015/16
2.
Submitted e-form (Google form)
Google form e-

Please return the application form and all supporting documents to the Student Affairs Office by 6
June 2016 (Mon).
2016 6 6
*Please ensure ALL documents are prepared and ALL boxes have been before the call for application
closes.
*

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Lutheran Academy 2015/16 Scholarship Scheme

2015/16
Academic/Music/Arts/Sports Scholarship Application Form

Type of Scholarship: *Academic/ Music/ Visual Arts/ Sports

Please circle the appropriate.

A. Students Particulars
Student
Name
1.

current
student

future
student

For Office Use only

1.

______________________________________
(Family Name)

(First Name)

(Preferred English Name)

______________________________________
()

()

______________________________________

Please affix a recent

photograph

School Email Address (For current student)

______________________________________
Personal Email Address (For future student)

2.

Gender Male / Female

4.

Date of Birth / /

5.

Place of Birth___________ 6. Nationality

3.

Age____________

(dd/mm/yyyy //)

__________

2.
3.
4.
5.
6.

7.

HK Identity Card No./ Passport No. * / *_____________________

7.
8.

8.

Religion_________________ 9. Application no. * ____________

9.

10-17)

10.

Correspondence English
Address
__________________________________________________

10.

__________________________________________________

__________________________________________________

11.

Contacts

__________________________________________________
Phone / Mobile No.
__________________________________________
E-mail Address (if applicable) ()
_______________________________

*Application no. can be found on the receipt of the application fee.

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11.

B. Parents Particulars
For Office Use only

12.

Name of Parent / Guardian /

12.

English___________________________________ :______________
13.

Home Tel. No.______________14. Mobile No._______________

13. 14.

15.

Office Tel. No._____________16. Relationship_____________

15. 16.

17.

E-mail Address _________________ 18. Occupation_____________

17. 18.

C. Portfolio Summary
I.

Previous School Information (in chronological order)

For

Office Use only

Name of school

Year attended

Class attended

19.

a.

b.

20.

a.

b.

21.

a.

b.

II.

19.
20.
21.

Academic Performance and Conduct (recent 2 final exams)

For Office Use only

Term

Conduct
grade

Class Position (if

any)

Form Position (if

any)

Average mark/
Grade

22.

a.

b.

c.

d.

23.

a.

b.

c.

d.

24.

a.

b.

c.

d.

25.

a.

b.

c.

d.

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22.
23.
24.
25.

III.

Extra-Curricular Activities/Services (recent 2 years records) /

For Office Use only

26.

26.

Activity
_________________________________________________________
_________________________________________________________

Service
_________________________________________________________
_________________________________________________________

27.

Activity

27.

_________________________________________________________
_________________________________________________________

Service
_________________________________________________________
_________________________________________________________

IV.

Attainments
u Academic (recent 2 years records) ()

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For Office Use only

Award / Scholarship

Issuing organization

Year awarded

28.

a.

b.

28.

29.

a.

b.

29.

30.

a.

b.

30.

31.

a.

b.

32.

a.

b.

33.

a.

b.

31.
32.
33.

Sports (Best THREE) (3)

For Office

Use only

Level of Participation
Types of Sports

A) HK representative
B) Sports association / club
representative
/
C) School team

Year of
Participatio
n

Best Results / Hong Kong

Ranking
/

34.
34.

a.

b.

c.

35.

a.

b.

c.

36.

a.

b.

c.

Music

35.
36.

For Office Use

only

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Vocal / Instrument

Name of examination

Highest Grade
achieved

Result with
Scores

37.

a.

b.

c.

38.

a.

b.

c.

39.

a.

b.

c.

40. *

37.
38.
39.
40.

Is the applicant a member of a choir / an orchestra? Yes No

If yes, please specify

________________________________________________________________
__________________________________________________

Other Achievements

For Office Use only

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41.
41. Achievement or activity includes but are not limited to: Service / Uniform Groups, Speech &
Drama, Art, Invention, other special talents. Please briefly describe your achievement and specify the
relevant information, including year awarded, issuing organization etc. / .
/ / / /

________________________________________________________________
__________________________________________________
__________________
________________________________________________________________
__________________________________________________
__________________
________________________________________________________________
__________________________________________________
__________________
________________________________________________________________
__________________________________________________
__________________
________________________________________________________________
__________________________________________________
__________________

* Please put a ! in the appropriate box. !

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D. [Applicable to applicants who are Year 7 or above] This part MUST be completed by
the student (i.e. applicant). The following questions are to be completed in the
applicants own handwriting.
[]
For Office Use only

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42. Which subject do you find most challenging? Explain why. 42.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
43. What do you gain or achieve from school?

43.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

44. Do you feel happy in your life now? Explain Why.

44.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
45. What value do you find most important that you learn from your parents? Explain why.

45.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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46. Write an essay (200-300 words) to explain why you apply for the scholarship. Also please
indicate your goals and plan for learning. 200-300

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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________________________________________________________________

46.

E. Declaration and Signature

I and my child __________________________ have
read and fully understood the information provided in the Notes on the Lutheran
Academy Scholarship scheme. I declare that the information provided by me and my
child in this application form and supporting documents are complete and true to the
best of my knowledge, also PART D is completed by my child in

his / her* own

handwriting. If false information is supplied, the application will be rendered null and
void. Should there be a change, I will immediately inform the school of such change in
writing.

Parent / Guardian *

Student (Applicant)

Name :
Signature :
Date :

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