Daniel Murphy Scholarship Fund - Class of 2024  Fall Application                                     Due date:  October 18,  2019 

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Page 1: PERSONAL INFORMATION

Student



Preferred Name / Nickname






Home Phone
Mobile Phone
Email Address



Specify who else the student lives with
Are you a Chicago Housing Authority ("CHA") resident or do you receive a CHA voucher?
residency will be verified


An applicant is a first generation student if his/her parents and/or grandparents did not graduate from a four year college or university..
Is anyone else in your family applying for the DMSF Scholarship?
Other Applicant Full Name/Relationship
Has anyone else in your family received a DMSF Scholarship?
Other Recipient Full Name/Relationship
How did you hear about the DMSF Scholarship?

Page 2: PARENT/GUARDIAN CONTACT INFORMATION

Mother














Father














Other Guardian














Page 3: APPLICANT QUESTIONNAIRE.  This section is to be completed by the student/applicant.

High Schools
What is your neighborhood public high school?



Interests
Select all sports in which you participate now:

Select all sports you wish to play during high school:

Select all arts in which you participate now:


Select all arts in which you wish to participate during high school:


List any hobbies:

Select organizations with which you are involved:

List any summer academic programs or other supplemental or enrichment work you completed outside of school:


Complete the Sentences

The happiest time
I am concerned about
One book I enjoyed
I am best at
Others would describe me as
I would like to be better at
I have traveled to
Please select only TWO  of the following three essay questions.  Complete the selected essay questions in fully developed paragraphs.
Essay Question 1: Tell us about your neighborhood and how it has shaped you. (Approximately 500 words)


Page 4: PARENT QUESTIONNAIRE. This section is to be completed by the parent/legal guardian of the applicant. Preguntas para la Madre, el Padre, o el guardián legal

What qualities does your child exhibit that make him/her a good scholarship candidate?                           ¿Qué cualidades posee su hija/hijo que la/lo hace una/un buena/buen candidata/candidato para esta beca?
What has your child done to demonstrate leadership?                                                                        ¿Explique que ha hecho su hija/hijo para demonstrar liderazgo o características de ser un lider?
Explain any significant factors that have positively or negatively impacted your child.                            ¿Explique algunos factores importantes que ha hecho un impacto, positivo o negativo, a su hija/hijo?
What circumstances make financial aid necessary for you and your family?                                               ¿Cuáles circunstancias hace la ayuda financiera una necesitad para su familia?
Why do you want your child to attend a private high school?                                                                      ¿Porque le gustaría que su hija/hijo asista a una secundaria privada?
Would you consider boarding school for your child?                                                                                      ¿Es posible que usted considere una escuela secundaria de internado para su hija/hijo?

What is the language or dialect spoken at home? ¿Qué idioma hablan en su casa?
If selected, you and your child will be interviewed separately. Interviews are conducted in English. Will you need a translator?                                                                                                                                                  ¿Las entrevistas son en inglés y usted y su hija/hijo serán separados. ¿Necesitará un traductor durante su entrevista?                                                                                                                                                   


Page 5: RECOMMENDATIONS

You must provide information for the three references listed below. If you participate in an extra curricular activity you can include an additional recommendation form but a fourth form is not required.  Your chosen recommenders will receive an email instructing them on how to complete the reference form online. 
7th Grade English/Language Arts Teacher
First Name
Last Name
Email
7th Grade Mathematics Teacher
First Name
Last Name
Email
Guidance Counselor or Principal
This should be either your current guidance counselor or your current principal, whoever knows you better.
First Name 
Last Name
Email;
Special Interest Person
This is an optional recommendation form. This should be someone who is familiar with a specific talent or accomplishment of yours in the area of athletics, the arts, student government, club membership etc.



Page 6: FINANCIAL INFORMATION.  This section is to be completed by the parent/legal guardian of the applicant.  DMSF requires information for both custodial and non-custodial parents.

Household Information

If applicant’s parents are separated, divorced, or have never been married, please provide the following information:
Year of divorce or separation:
Is there a joint custody agreement?
Is there a parent living elsewhere with whom the applicant has contact or who provides any financial support?
Total number of adults living in the household:
Total number of children living in the household:
Parent/Guardian A






Parent/Guardian B






Enter all other people living in the home. Include name, age, and whether the person is a dependent or adult. For adults, include the occupation & employer if applicable. For dependents, indicate the school or preschool name, its annual cost, and who is paying for portions of that cost. 
Parents/Guardian Monthly Income & Expense Information for 2018 (round to the nearest hundred dollars - no decimals)
1. Parent/Guardian A—Total income expected from all sources (before taxes)
2. Parent/Guardian B—Total income expected from all sources (before taxes)
3. Earnings of any adult with whom domestic expenses are shared (before taxes)
4. Social Security Benefits received for all family members
5. AFDC or General Assistance expected
6. Child Support expected
7. Non-taxable income expected
8. Other taxable income expected
9. Sum of items 1-8
10. Rent or Mortgage Payment (including property taxes/insurance)
11. Transportation / Auto
12. Food, Clothing, Utilities
13. Total medical/dental expenses not reimbursed by insurance companies
14. Support payments to former spouse
15. Insurance (Life, Auto, etc.)
16. Elementary & secondary school tuition payments
17. Other unusual or extraordinary expenses
18. Sum of items 10-17
Who else, if anyone, is providing any financial support to applicant or family?
How much (per year)?
Amount of tuition you can afford for the next school year:
Do you expect any significant change to your income next year?
If so, please explain:
Assets & Debts
Home
Unpaid second mortgage or home equity loan:
Do you own any other real estate?
Other Real Estate
Year purchased:
Purchase price:
Unpaid principal:
Annual payments on all other real estate:
Do you own or co-own a business or farm?
Business/Farm
Total Assets:
Total Debts:
Accounts
(please list average balance if applicable)
Investments, stocks, bonds, mutual funds:
do not include retirement accounts
Retirement plans, IRA’s, SEP’s or Keoghs:
Vehicles
List all family cars (year, make, model)
 


Financial File Uploads:  An application is not complete without submission of financial documents.  All parents, custodial or non-custodial, and legal guardians are required to submit tax documentation (1040s and W-2s for 2017, or any other pertinent financial documents).  Please scan and upload all pertinent financial documents for review.  An application will not be considered if the requested financial documents are missing.






Carefully Read and Sign the Following:
I/We declare that the information reported on this form, to the best of our knowledge and belief, is true, correct and complete. I/We recognize that intentionally providing false information may impact our ability to receive any financial aid/or our child's right to become or remain a DMSF scholar. I/We authorize DMSF to share this application with DMSF's partnership schools. I/We acknowledge that all statements made in this application are made for the purpose of obtaining financial aid; any agent or employee of DMSF or its partner schools may verify or re-verify any information contained in the application from any sources named in this application; DMSF may continuously rely on the information contained in the application; and I/we are obligated to amend and/or supplement the information provided in this application if any of the facts that I/we have represented should change.