Altrusa Scholarship Application

University of Wisconsin–Madison Division of Continuing Studies

Altrusa Grant Fund Madison Chapter Scholarship Application

Application deadlines: June 15 and October 15

Please type or print clearly.

Attach the following to the completed application

One letter from a counselor verifying that an educational/career assessment*
One letter of support from someone affiliated with a social service agency, a neighborhood center, a religious institution, a community organization, or an educational institution.

*(Example: meeting with an academic advisor, completing a vocational inventory, receiving career counseling, attending an orientation/advising program.)

Name ( Last, First, Middle)

Address (Street, City, State, Zip)

Age ( ) Phone ( )

Apply to term beginning

Fall, 20_____ Spring, 20______

What educational course or program do you wish to pursue?

Date course(s) begins ( )

How does this program fit with your career goals?

Educational experience

High School Graduation: (circle one) GED Diploma Date: ( )

Post High School Experience: If you have post high school education, please provide a copy of all transcripts.

School/College Location Attended From/To Course of Study Degree Earned

Educational institution in which enrollment is desired

Institution's name

Address (City, State)

Course of study

Expected date of program completion

Verification of acceptance, such as a letter from the admissions office, will be required before funds are released. OR

Educational institution currently attending

Institution's name

Address (City, State)

Course of study

Expected date of program completion

Will you be in good academic standing (eligible to continue) at the end of this term? (Circle One) Yes No

Financial information

Actual dollars & source of funds available to you (and your spouse or partner.) Actual Expenses

Income: Expenses may include:

Wages (full or part-time) $ Child Care $

Scholarships $ Housing $

Loans $ Food $

Other sources $ Utilities $

Car Payments $

Medical $

Other $

TOTAL $ TOTAL $

Please describe the nature of your educational hardship

(Feel free to attach additional pages.)

Special circumstances

Please add additional information, if any, that you think the scholarship committee should take under consideration.

(Feel free to attach additional pages.)

I attest that the information provided is complete and accurate and that the grant will be used for education-related costs.

Signature and Date

Scholarship List Information

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