application form (PDF) - Special School District

2014-2015Allison M. HaakeMemorial ScholarshipApplication formApplications are due Friday, Feb. 13, 2015Established in 2008, the Allison M. Haake Memorial Scholarship is awarded to a deserving SSD student whohas an interest in working with children. The scholarship was established in memory of Allison Marie Haake, aformer SSD teacher assistant. Allison was an inspirational teacher who, at an early age, knew she wanted to makea career of working with children. The recipient of the scholarship will be honored at the annual Commitment toKids Banquet on April 23, 2015.Please complete the entire form and return it to the Communications Department by e-mail towbuchek@ssdmo.org; by mail (12110 Clayton Road, Town & Country, MO 63131); or by fax (314.989.8470).Contact Wes Buchek at 314.989.8102 with questions.Scholarship Guidelinesu Students must receive at least one special education service from SSD and/or attend an SSD technical high school.u The essay portion (Part III) of the application must be completed by the student.u Students must be seniors during the 2014-2015 school year.u Applicants must have experience working with children (i.e. summer camp counselor).u Applicants may include one letter of recommendation up to two pages in length.r Please check box if a letter of recommendation will be sent separately.Part I - Applicant InformationName:Birthdate:Home Address:City: State: Zip:E-mail:Service(s) Applicant Receives from SSD:Applicant Signature:Date:q For electronic submissions, in lieu of a signature, by cecking box you verify all above information is accurate.Parent/Guardian Name:Parent Signature (if applicant is a minor):Date:q For electronic submissions, in lieu of a signature, by cecking box you verify all above information is accurate.Parent Address (if different from applicant):City: State: Zip:Parent Daytime Phone:Parent Evening Phone:Page 1 of 5

2014-2015Allison M. HaakeMemorial ScholarshipApplication formApplications are due Friday, Feb. 13, 2015Part III - Applicant Essay (continued)3. Provide information on volunteer or work experience directly involving children.Page 5 of 5