Dual Credit Course Assistance Program
School:
Truman
Van Horn
William Chrisman
Summary:
Dual Credit courses allow you to take classes for college credit while you are still in high school. This
program offers a great way to get a head start on your college education. The ISD Foundation has
scholarships available for students that qualify for this opportunity (see criteria below). Please see your
high school counseling office for more information about this program.
You must be accepted into the Dual Credit Course Program by the following College or University:
 Drury University
 Metropolitan Community Colleges
 NW Missouri State University
 Truman State University
 UMKC-University of Missouri-Kansas City.
APPLICATION INFORMATION:
Criteria / Requirements:
1.
2.
3.
4.
5.
Completion of the Scholarship Application
Completion of the Family Financial Statement (must include parent/guardian most recent W-2)
Attach a brief essay that includes your career goals and how this scholarship will help you achieve them
Acceptance into the Dual Credit Course program
Participation in Project Shine or 8 hours of approved volunteer work (must complete attached form)
APPLICATION DUE IN YOUR SCHOOL COUNSELING OFFICE BY
November 21st, 2014
4:00pm
Selection:
Established 2014
Recommendation of recipient made under the direction of the Secondary Education Committee.
School District of Independence Foundation
Application
Dual Credit Course Assistance
Name
Last Name
First Name
Middle Name
Street Address
City
State
Zip (+ 4 Digit)
High School Attending
Date of Birth
Home Phone (
Male
)
Female
Cell Phone (
)
Parent/Guardian Name
Street Address
City
Home Phone (
State
)
Student E-Mail
-
Zip (+ 4 Digit)
Work Phone
(
)
-
-
Parent E-Mail
By submitting this application, the undersigned hereby certifies that the information contained herein is true and
accurate as of the date signed. The undersigned further authorizes the Independence School District and The School
District of Independence Foundation, Inc. to release any and all education records of the applicant and any other
information necessary for due consideration of this application. The undersigned hereby releases and forever
discharges the Independence School District, The School District of Independence Foundation, Inc. and Donors
from any and all claims, damages and liabilities associated with the release of said information.
Applicant Signature
Date
Parent or Guardian Signature
Date
Rev. November 2013
FAMILY FINANCIAL STATEMENT for Dual Credit Course Assistance
Name of applicant:
(Last)
(First)
(Middle)
Father or Guardian
Mother
1. Name
Name
2. Home Address
Home Address
3. Employer
Employer
Parent’s Annual Income (before taxes)
Annual 2014
Estimated 2015
Father
$
Father
$
Mother
$
Mother
$
Total
$
TOTAL $
Please list all brothers & sisters of the applicant & indicate the extent of family financial support siblings are receiving during the current/upcoming
academic year.
Name
School/College/or Occupation
Age
Support Given
In College
1.
Y/N
2.
Y/N
3.
Y/N
4.
Y/N
Describe personal, family or financial circumstances that make it necessary for you to seek aid for your dual credit course study.
Student
Are you receiving free or reduced lunch this school year?
Are you currently employed or have you been employed in the last year?
If yes, what is the average number of hours worked per week?
Hourly rate?
Accepted into Dual Credit Course program at:




Drury University
Metropolitan Community Colleges
Northwest Missouri State University
University of Missouri-Kansas City
How many dual credit courses will you be taking this school year?
_____________________________________________________
__________________________________________________
Applicant Signature
Father/Guardian Signature
_____________________________________________________
__________________________________________________
Date
Mother Signature
Rev. September 2014
Dual Credit Course Assistance Program
Volunteer Hours
All students are required to volunteer at the annual ISD Project Shine in July. If
you are unable to attend Project Shine, you will need to get special approval from
your counselor for other District or community volunteer work.
**Required volunteer hours must be in addition to any A+ volunteer hours.
Name of Participant:
Date of Service:
Service:
Organization:
Address:
Nature of Service:
Number of Hours:
Service Representative:
Please Print Name:
Phone:
Signature:
Signature of Student:
(Please Print)