__________________________________ A p p l i c a n t Na m e

__________________________________ e l e m e n t ar y s c h o o l

Class of 2018 application

1

The Daniel Murphy Scholarship Fund

309 West Washington, Suite 1250 • Chicago, IL 60606 • (312) 455 - 7800

Completed Applications Must Be Submitted to DMSF’s Office Applications can be submitted via US mail or delivered to the DMSF office (not faxed or emailed) Monday – Friday, 9 a.m. – 5 p.m. Mailed applications must be postmarked by the deadline. A pp l ication D ead l ine : F riday, O cto b er 2 5 , 2 0 1 3

Recommended deadline for those applicants interested in boarding school: October 11, 2013

A pp l ication C h ec k l ist Applicants: Please enclose completed application and all materials in a large envelope. Incomplete applications will not be considered. If there is more than one application submitted per household, please submit all in one envelope. I have completed/enclosed the following: STUDENTS

R E C O M M E N DAT I O N S

ˆˆ Personal Information Sheet (p.2) ˆˆ Applicant Questionnaire (p.3) ˆˆ Personal Essay I (p.5) ˆˆ Personal Essay II (p.6) ˆˆ Given the recommendation forms to appropriate teachers/administrators (p.7-12) ˆˆ Reviewed/signed the signature page (p.15)

ˆˆ 7th Grade English / Language Arts Teacher recommendation (in a sealed envelope) (p.7-8)

PA R E N T / G U A R D I A N ˆˆ Parent Questionnaire (p.4) ˆˆ Reviewed/signed the Signature Page (p.15) ˆˆ Copy of divorce decree and/or court order appointing guardianship (if applicable) ˆˆ Financial Information section (pages 13-14) ˆˆ Copy of all W-2’s for custodial and non-custodial parents ˆˆ Copy of 2012 Federal Income Tax Returns (including all schedules) for custodial and noncustodial parents ˆˆ Documentation of non-taxable income (e.g. child support, public assistance)

ˆˆ 7th Grade Mathematics Teacher recommendation (in a sealed envelope) (p.9-10) ˆˆ Guidance Counselor/Principal recommendation (in a sealed envelope) (p.11-12). Guidance Counselor/ Principal has also provided: ˆˆ Copy of 7th grade report card (all marking periods) and 8th grade report card (if available) ˆˆ Copy of most recent standardized test scores (i.e., ISAT, Terra Nova) ˆˆ Copy of NWEA, Explore, ISEE, or SSAT scores (if available) ˆˆ Copy of Transcript/Cumulative Grade Report (if available)

*Applications will not be considered if the financial section is incomplete or if requested financial documents are missing.

To what schools are you interested in applying? Public School _______________________________________

Boarding School _______________________________________

Private School ______________________________________

Boarding School ________________________________________

Private School ______________________________________

What is your neighborhood public high school?_______________________________________

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Class of 2018 application

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P ersona l I nformation •••••Student

- Personal Data

________________________________________________________________________________________________________________________ First Middle Name Last Name Preferred name or nickname ________________________________________________________________________________________________________________________ Home Address Apt. City State Zip Code ________________________________________________________________________________________________________________________ Home Telephone (include area code) Cell Phone (include area code) E-mail Address  Male  Female ________________________________________________________________________________________________________________________ Date of Birth (Mo / Date / Year) Birthplace (City, State, Country) Ethnicity

 African-American

Student Lives With (Select all that apply)

Father

 Asian

Bi-racial

 Mother

 Caucasian

Step-Father

Hispanic

 Step-Mother

Multi-racial

Legal Guardian

 Other ______________  Other________________

Emergency Contact _______________________________________________________________________________________________________ Name Relationship to applicant Phone Number Are you a Chicago Housing Authority (CHA) resident or do you receive a CHA voucher? Yes

••••••Mother

No Client ID # _______________________ (residency will be verified)

- Personal Data (Complete as fully as possible)

__________________________________________________________________________________ First Name Middle Name Last Name



Deceased

 Disabled

Age _____

________________________________________________________________________________________________________________________ Daytime Phone (include area code) Evening Phone (include area code) Cell Phone (include area code) Email address ________________________________________________________________________________________________________________________ Address Apt. City State Zip Code Education:  Elementary School

• • • • • Fat h e r

 High School Graduate

 College Graduate

 Pursuing College Degree

 Post-Graduate

- Personal Data (Complete as fully as possible)

__________________________________________________________________________________ First Name Middle Name Last Name



Deceased

 Disabled

Age _____

________________________________________________________________________________________________________________________ Daytime Phone (include area code) Evening Phone (include area code) Cell Phone (include area code) Email address ________________________________________________________________________________________________________________________ Address Apt. City State Zip Code Education:  Elementary School

•••••Guardian

 High School Graduate

 College Graduate

 Pursuing College Degree

 Post-Graduate

- Personal Data (if applicable)

__________________________________________________________________________________ First Name Middle Name Last Name



Deceased

 Disabled

Age _____

________________________________________________________________________________________________________________________ Daytime Phone (include area code) Evening Phone (include area code) Cell Phone (include area code) Email address ________________________________________________________________________________________________________________________ Address Apt. City State Zip Code Education:  Elementary School

 High School Graduate

 College Graduate

 Pursuing College Degree

 Post-Graduate

application deadline: Friday, October 25, 2013

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Class of 2018 application

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A pp l icant Q uestionnaire This section is to be completed by the applicant in his/her own handwriting. Sports

Select all sports you wish to play during high school: Select all sports you participate in now:  Baseball  Track and Field  Basketball  Wrestling

 Hockey  Gymnastics  Volleyball  Soccer  Golf  Football  Other _________________

Music/Arts

Select all that you play/participate in now:  Guitar  Violin  Trumpet  Vocal/Choir  Theatre  Dance  Visual Arts  Piano  Flute  Drums  Other ______________ How long have you played/participated? ______________

 Baseball  Track and Field  Basketball  Wrestling

 Hockey  Gymnastics  Volleyball  Soccer  Golf  Football  Other _________________

Select all that you wish to play/participate in during high school:  Guitar  Violin  Trumpet  Vocal/Choir  Theatre  Dance  Visual Arts  Piano  Flute  Drums  Other ______________

Hobbies

Please list: ________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Organizations

Select those with which you are involved:  Boy/Girl Scouts  HighSight  Boys and Girls Club of America (club name) ___________________________  Metro Squash  Metro/Midtown  Merit School of Music  Horizons for Youth  High Jump  Other (specify) __________________________________________________

Complete the Sentence 1. The happiest time _________________________________________________________________________________ 2. I am concerned about ______________________________________________________________________________ 3. One book I enjoyed _______________________________________________________________________________ 4. I am best at _____________________________________________________________________________________ 5. Others would describe me as ________________________________________________________________________ 6. I would like to be better at __________________________________________________________________________ 7. I have traveled to _________________________________________________________________________________ List any volunteer work you have done, including the location and your responsibilities: _____________________________ __________________________________________________________________________________________________ List any academic honors, awards, prizes or scholarships you received over the last two years: _______________________ __________________________________________________________________________________________________ List any summer academic programs or other supplemental or enrichment work you completed outside of school: ________ __________________________________________________________________________________________________ List high schools you have visited or at which you have shadowed: _____________________________________________ __________________________________________________________________________________________________ application deadline: Friday, October 25, 2013

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Class of 2018 application

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P arent Q uestionnaire 1. What qualities does your child exhibit that make him/her a good scholarship candidate? ________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 2. What has your child done to demonstrate leadership? ____________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 3. Explain any significant factors that have positively or negatively impacted your child. ___________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 4. What circumstances make financial aid necessary for you and your family? ____________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 5. Why do you want your child to attend a private high school? _______________________________________ __________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 6. Would you consider boarding school for your student? ___Yes ___No 7. What is the language or dialect spoken at home? ______________________________________________ If selected, you and your child will be interviewed separately. Interviews will be conducted in English. Will you need a translator? ¿Necesitará un traductor durante la entrevista?  Yes  No Name ________________________________ Relationship to applicant________________________________ application deadline: Friday, October 25, 2013

__________________________________ A p p l i c a n t Na m e

Class of 2018 application

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P ersona l E ssay I Instructions for the student: Please write your response to the following question directly on this page in your own handwriting. Try to use only the space provided.

Question: Tell us about your neighborhood and how it has shaped you. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Applicant Signature _____________________________ application deadline: Friday, October 25, 2013

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Class of 2018 application

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P ersona l E ssay I I Instructions for the student: Please write your response to the following question directly on this page in your own handwriting. Try to use only the space provided.

Question: Describe a difficult situation you have been in and how it was resolved. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Applicant Signature _____________________________ application deadline: Friday, October 25, 2013

__________________________________ A p p l i c a n t Na m e

Class of 2018 application

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E ng l is h / Language A rts T eac h er R ecommendation Instructions for the student: Please print your name below and give this form to your 7th grade English/Language Arts teacher. Submit the recommendation in a sealed envelope from your teacher with your completed application.

Student’s Name ____________________________________________________________________________________ Last First Middle

Instructions for the parent/guardian: Please read and sign the following statement.

I acknowledge that I waive my right to read the confidential teacher recommendation for the student named above. Name of parent/guardian __________________________________________________ Signature of parent/guardian _______________________________________________ Date _________

Instructions for the teacher: The above named student is a candidate for a Daniel Murphy Scholarship. The Selection

Committee appreciates the help you are able to give us in our evaluation of this candidate. We depend on and value your assessment. Your recommendation may be shared with DMSF partnership schools. Please place this recommendation in a sealed envelope with the student’s name written on the front, sign the envelope across the back flap and return it to the student. 1. How long and in what capacity have you known the candidate? __________________________________________________________________________________________________ 2. In relation to others in the candidate’s age group, please rate the candidate by checking the appropriate boxes. Excellent Above Average Average Below Average     Academic potential     Ability to work independently     Imagination/creativity     Intellectual curiosity     Oral expression     Effort/persistence     Study habits     Conduct     Concern for others     Emotional stability     Maturity     Organization     Personal integrity     Peer compatibility     Relationship to adults     Responsibility     Self-confidence     Overall evaluation as a person    Overall evaluation as a student  application deadline: Friday, October 25, 2013

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Class of 2018 application

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E ng l is h / Language A rts T eac h er R ecommendation 3. Does the applicant possess any particular strengths or weaknesses of which we should be aware? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4. Please give us a brief course description. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 5. How well does the student write in comparison with other students in the class? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 6. Please comment on the student’s ability to learn from his or her mistakes. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 7. Compared to other students in your English class, how would you rank this student? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 8. What else would you like us to know about this student? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 9. Please list the subject(s) you teach or have taught to the applicant. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Thank you for taking time to complete this evaluation. All information provided will be kept in strict confidence. __________________________________________________________________________________________ School Name

Street

______________________________________________ School phone number

City

State

Zip code

_________________________________________________________________ Teacher’s Name

___________________________________________________ ________________________________________________ __________________ Teacher’s E-mail Address Signature Date

Seal this recommendation in an envelope with your signature across the back flap. return it to the student with their name written on the front.

__________________________________ A p p l i c a n t Na m e

Class of 2018 application

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M at h ematics T eac h er R ecommendation Instructions for the student: Please print your name below and give this form to your 7th grade math teacher. Submit the recommendation in a sealed envelope from your teacher with your completed application.

Student’s Name ____________________________________________________________________________________ Last First Middle

Instructions for the parent/guardian: Please read and sign the following statement.

I acknowledge that I waive my right to read the confidential teacher recommendation for the student named above. Name of parent/guardian __________________________________________________ Signature of parent/guardian _______________________________________________ Date _________

Instructions for the teacher: The above named student is a candidate for a Daniel Murphy Scholarship. The Selection

Committee appreciates the help you are able to give us in our evaluation of this candidate. We depend on and value your assessment. Your recommendation may be shared with DMSF partnership schools. Please place this recommendation in a sealed envelope with the student’s name written on the front, sign the envelope across the back flap and return it to the student. 1. How long and in what capacity have you known the candidate? __________________________________________________________________________________________________ 2. In relation to others in the candidate’s age group, please rate the candidate by checking the appropriate boxes. Excellent Above Average Average Below Average     Academic potential     Ability to work independently     Imagination/creativity     Intellectual curiosity     Oral expression     Effort/persistence     Study habits     Conduct     Concern for others     Emotional stability     Maturity     Organization     Personal integrity     Peer compatibility     Relationship to adults     Responsibility     Self-confidence     Overall evaluation as a person    Overall evaluation as a student  application deadline: Friday, October 25, 2013

Class of 2018 application

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M at h ematics T eac h er R ecommendation 3. Does the applicant possess any particular strengths or weaknesses of which we should be aware? ___________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. What course is the student currently taking?  Pre-Algebra  Modified Algebra  Algebra I  Algebra II  Geometry  Other ___________ 5. How is the course the student is presently taking best described?  Gifted Class



Special Ed



Other _____

6. What course would you recommend this student take in ninth grade? Please check only one.  Algebra I  Honors Algebra I  Geometry  Honors Geometry  Algebra II 7. Please comment on the student’s work in mathematics. ______________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 8. Please comment on the student’s ability to learn from his or her mistakes. _______________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 9. Compared to other students in your math class, how would you rank this student? _________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 10. What else would you like us to know about this student? ___________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 11. Please list the subject(s) you teach or have taught to the applicant. ___________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Thank you for taking time to complete this evaluation. All information provided will be kept in strict confidence. __________________________________________________________________________________________________________________________ School Name Street City State Zip code _______________________________________________________ __________________________________________________________________ School phone number Teacher’s Name _______________________________________________________ _______________________________________________________ __________ Teacher’s E-mail Address Signature Date

Please understand that DMSF places great reliance on teacher recommendations. Seal this recommendation in an envelope with your signature across the back flap. return it to the student with their name written on the front.

__________________________________ A p p l i c a n t Na m e

Class of 2018 application

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G uidance C ounse l or / P rincipa l R ecommendation Instructions for the student: Please print your name below and give this form to your current Guidance Counselor/ Principal. Submit the recommendation in a sealed envelope from your teacher with your completed application.

Student’s Name ____________________________________________________________________________________ Last First Middle

Instructions for the parent/guardian: Please read and sign the following statement.

I acknowledge that I waive my right to read the confidential teacher recommendation for the student named above. Name of parent/guardian __________________________________________________ Signature of parent/guardian _______________________________________________ Date _________

Instructions for the Guidance Counselor/Principal: The above named student is a candidate for a Daniel Murphy Scholarship. The Selection Committee appreciates the help you are able to give us in our evaluation of this candidate. We depend on and value your assessment. Your recommendation may be shared with DMSF partnership schools. Please place your recommendation in a sealed envelope with the student’s name written on the front, sign the envelope across the back flap and return it to the student. Please also provide the following items to the student, to be submitted to DMSF with the student’s application:

ˆˆ ˆˆ ˆˆ ˆˆ

Copy of Copy of Copy of Copy of

7th grade report card (all marking periods) and 8th grade report card (if available) most recent standardized test scores (i.e., ISAT, Terra Nova, etc.) NWEA, Explore, ISEE, or SSAT scores (if available) Transcript/Cumulative Grade Report (if available)

School Year runs from: __________ to: ___________ Number of students in applicant’s grade: _____________ Check the classification of your school:  Public  Private  Bilingual  Magnet

 Gifted

 Other (specify) ____________

Does your school have a ranking system?  Yes  No If so, is your rank:  Approximate  Exact The applicant ranks ______ out of _______ Are the students placed in sections according to ability?  Yes  No If the student’s attendance record is not listed on the transcript, please indicate the number of days he/she has been absent or tardy each year. _________________________________________________________________ _______________________________________________________________________________________ Has the student ever been dismissed, suspended, placed on probation or received other serious disciplinary sanctions?  Yes  No To your knowledge, has the student ever failed to be in good academic standing?

 Yes

 No

Has the student ever been asked to repeat a grade or withdraw from a school for any reason? Does the student have an Individualized Education Program (IEP)?  Yes

 Yes

 No

 No

If the answer to any of these questions is yes, please provide a full explanation on a separate piece of paper.

application deadline: Friday, October 25, 2013

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Class of 2018 application

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G uidance C ounse l or / P rincipa l R ecommendation In relation to others in the candidate’s age group, please rate the candidate by checking the appropriate boxes. Academic potential Ability to work independently Imagination/creativity Intellectual curiosity Oral expression Effort/persistence Study habits Conduct Concern for others Emotional stability Maturity Organization Personal integrity Peer compatibility Relationship to adults Responsibility Self-confidence Overall evaluation as a person Overall evaluation as a student

Excellent

Above Average Average

Below Average

Unable to comment

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Please provide us with any information that will give us a more complete picture of the student. ______________ __________________________________________________________________________________________ __________________________________________________________________________________________ Thank you for taking time to complete this evaluation. All information provided will be kept in strict confidence. Signature of Person who completed form _________________________________________________________ Title________________________________________________________Date___________________________ __________________________________________________________________________________________ School Name

Address

City

State

Zip code

_______________________________________________ ___________________________________________________________________ Principal’s Name

Principal’s email address

__________________________________________________ ___________________________________________________________________ Guidance Counselor’s name

Guidance Counselor’s email address

Please understand that DMSF places great reliance on Guidance Counselor/Principal recommendations. Seal this recommendation in an envelope with your signature across the back flap. return it to the student with their name written on the front.

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Class of 2018 application

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A nnua l I ncome and E x pense I nformation Please complete the following section. We cannot consider the student’s application if this section is not complete. If the student has a non-custodial parent, please print another copy of page 13 and 14 and have the non-custodial parent complete this section as well. Non-custodial parents are also expected to submit W-2’s, 2012 Federal Income Tax returns, and any other pertinent documents.

Parent/Guardian A __________________________________________________________________________________________

Full Name Relationship to Applicant ________________________________________________________________________________________________________________________ Employer Name Employer’s Telephone Number Occupation/Title Years with Company  part time  full time

Household Status (please check one of the following):

 Married, two parent household  Single parent receiving child support

 Single parent providing all financial support  Single parent sharing expenses with another adult (spouse or other)

If applicant’s parents are separated, divorced, or have never been married, please provide the following information:  divorced  separated, no court action  legally separated  never married Is there a joint custody agreement? Yes  No Year of divorce or separation_______ Is there a parent living elsewhere with whom the applicant has contact or who provides any financial support?  Yes  No

Parent/Guardian B __________________________________________________________________________________________

Full Name Relationship to Applicant ________________________________________________________________________________________________________________________ Employer Name Employer’s Telephone Number Occupation/Title Years with Company  part time  full time

Parents/Guardian Income and Expense Information for 2013

(round to the nearest hundred dollars)

( Monthly)

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

$____________

11. Real Estate Taxes

$____________

12. Total federal tax paid (2012 IRS 1040 or 1040A)

$____________

13. Transportation / Auto

$____________

14. Food, Clothing, Utilities

$____________

15. Total medical/dental expenses not reimbursed by insurance companies

$____________

16. Support payments to former spouse

$____________

17. Insurance (Life, Auto, Home)

$____________

18. Elementary & secondary school tuition payments

$____________

19. Other unusual or extraordinary expenses (please explain on a separate sheet of paper)

$____________

20. Sum of items 10-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$____________

Who else, if anyone, is providing any financial support to applicant or family? ___________________________ If so, how much (per year)? $________________ Amount of tuition you can afford for the 2014-2015 school year $______________ Do you expect any significant change to your income in 2014?  Yes If so, please explain these changes on a separate sheet of paper. *Applications will not be considered if the financial section is incomplete or if requested financial documents are missing.

 No

application deadline: Friday, October 25, 2013

__________________________________ A p p l i c a n t Na m e

Dependents

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(If additional space is needed, attach seperate sheet of paper)

Full Name

Name of child care, preschool, school or college

Age

Annual cost of child care, preschool, school or college

Amount of the cost paid by:

Parent or guardian

Loan

Student’s assets and earnings

Friends, relatives and other sources

1. 2. 3. 4. 5.

All others living in household (if additional space is needed, attach separate sheet of paper) __________________________________________________________________________________________________ Relationship Age Name Occupation and Employer __________________________________________________________________________________________________ Relationship Age Name Occupation and Employer __________________________________________________________________________________________________ Relationship Age Name Occupation and Employer Total number living in home: _______ Family Assets and Debts 1. Home (if owned) Year Purchased ________ Purchase Price $____________ Unpaid Principal on Mortgage $________ Annual payments on 1st mortgage $______

2. Do you have a second mortgage or home equity loan?  Yes  No If yes, unpaid balance $__________

3. All other real estate Year Purchased ________ Purchase Price $_______________ Unpaid Principal on Mortgage $______ Annual payments on all other real estate:$ ____________

4. Bank accounts (please list average balance if applicable) Checking $_____________ Savings $_______________ 5. Investments, stocks, bonds, mutual funds (please do not include retirement accounts) $__________________________ 6. Retirement plans, IRA’s, SEP’s or Keoghs $ __________________________ 7. List all family cars (year, make, model) Total Car Debt $_______________ 1.____________________________________________  Own  Lease Monthly Car Payment $___________ 2.____________________________________________  Own  Lease 3.____________________________________________  Own  Lease 8. Total debt not listed above __________________________ 9. Do you own or co-own a business or farm?  Yes  No If yes: percentage ownership_______ Its assets $________ Its debts $________ application deadline: Friday, October 25, 2013

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Is anyone else in your family applying for the DMSF Scholarship?  Yes  No Name / Relationship ___________________________________________ Has anyone else in your family received a DMSF Scholarship?

 Yes

 No

Name/ Relationship ___________________________________________ How did you hear about the DMSF Scholarship? ___________________________________________________

C arefu l l y read and sign t h e fo l l o w ing : 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 and/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. Without signatures of applicant and parent/guardian(s), we cannot consider this application. _____________________________________________ _______________ Applicant Signature Date _____________________________________________ _______________ Parent/Guardian Signature Date _____________________________________________ _______________ Parent/Guardian Signature Date

T H I S A P P L I C A T I O N A N D A LL M A T E R I A L S S U B M I T T E D W I T H I T A R E T H E P R O P E R T Y O F D M S F A N D W I LL N O T B E R E T U R N E D .

application deadline: Friday, October 25, 2013

Class of 2018 application

16

S c h o l ars h ip and A pp l ication G uide l ines

Thank you for your interest in applying for a Daniel Murphy Scholarship. Please review the following list of frequently asked questions and answers. Frequently Asked Questions

1. What is the Daniel Murphy Scholarship Fund?

The Daniel Murphy Scholarship Fund (DMSF) is a non-profit organization that gives high school scholarship assistance and educational support to Chicago students from economically disadvantaged backgrounds. DMSF seeks to make a life-altering difference in the lives of its Scholars by providing them with the best opportunity to succeed in high school and college.

2. What are the qualifications for the DMSF scholarship?

Eighth graders who have demonstrated academic potential, strong character, and financial need are encouraged to apply. Financial need generally means families whose income is under $65,000. Applications are only accepted from students who will be freshman in the 2014 - 2015 school year. Students must live in Chicago, Cicero or Berwyn.

3. How do I demonstrate financial need?

Complete the financial information form (p.13 and 14) and provide proof of income (2012 W-2’s and 1040’s, and/or proof of public assistance). We need full financial disclosure from both custodial and non-custodial parents. Scholarships are awarded to those who demonstrate that attending a private high school without financial assistance would be impossible.

4. How many scholarships will you award?

DMSF will award approximately 100 scholarships to students who are currently in 8th grade and will be entering high school during the 2014-2015 school year.

5. What is the application deadline?

The deadline is Friday, October 25, 2013. Applications can be downloaded from our website (www.dmsf.org). Completed applications must be delivered to DMSF’s office or postmarked by October 25, 2013. Applications may be turned in at the High School Fair on October 8, 2013. Due to the large number of applications it expects to receive, DMSF cannot verify if an application has been received.

6. Can the scholarship be applied to any school?

No, the scholarship only applies to DMSF partnership schools. DMSF retains the right to limit the scholarship award to a specific school or schools.

7. Does the family pay anything?

Yes, each family is required to pay a portion of their child’s educational expenses. Families will be responsible for a portion of the tuition and any additional supplementary fees, including but not limited to books, uniforms, technology fees, and registration fees. The average family contribution for a family is $2,500 per school year.

FAQ continued ...

Class of 2018 application

17

... FAQ continued

8. How do I obtain information about DMSF partnership schools?

• Attend the DMSF High School Fair, which will be held in on October 8, 2013 at St. Ignatius College Prep (1076 W. Roosevelt Road). Please check our website (www.dmsf.org) for more details. • Check the DMSF website for names of partnership schools and visit the school websites.

9. How does the application process work and when will I be notified of my status?

After the deadline, applications are considered on a rolling basis. Students may be informed that they have been selected for an interview any time between October and January. Students who are not selected for an interview will receive a letter in late February 2014. Phase 1 • Completed applications are reviewed through early November. Phase 2 • From October through January, approximately 200 qualified applicants and their parent/guardian(s) will be invited to interview. • Applicants will be notified via telephone of their interview appointment. Phase 3 • Applicants who have been interviewed will be notified by mail of their scholarship status within two weeks of the interview. • Applicants not selected for an interview will receive notification of their status in the mail by late February 2014. Phase 4 • Scholarship awards will not be final until the applicant completes the steps that follow: • Take the appropriate school admissions test(s) • Apply to a DMSF partnership school • Be admitted into a DMSF partnership school • Sign a scholarship confirmation agreement • Register at the school by the school’s deadline • Complete the school’s financial aid forms by the school’s deadline and receive financial aid from school • Mail a copy of the school’s acceptance letter and financial aid award letter to DMSF • Attend DMSF’s mandatory two-week summer program • Sign a DMSF scholarship contract

Please call schools directly or visit their websites for information regarding open houses, application deadlines, entrance exam dates, etc. Class of 2018 application

Day Schools:

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(Coed) - Co-Educational (B) - Boys (G) - Girls

 The entrance exam for Catholic schools will be held on Saturday, January 11, 2014 17 Chicago Academy for the Arts (Coed) www.chicagoacademyforthearts.org 12 Chicago Hope Academy (Coed) www.chicagohopeacademy.com 32 Chicago Waldorf School (Coed) www.chicagowaldorf.org 37 Christian Heritage Academy (Coed) www.christianheritage.org 42 Christ the King Jesuit (Coed) www.ctkjesuit.org 11 Cristo Rey Jesuit H.S. (Coed) www.cristorey.net 10 DeLaSalle Institute (Coed) www.dls.org 21 Fenwick High School (Coed) www.fenwickfriars.com 20 Francis W. Parker School (Coed) www.fwparker.org 18 Global Citizenship Experience (Coed) www.globalcitizenshipexperience.com 41 Gordon Tech (Coed) www.gordontech.org 26 Guerin College Prep (Coed)  www.guerinprep.org 30 Hanna Sacks Bais Yaakov High School(G) 16 Holy Trinity (Coed)  www.holytrinity-hs.org 31 Ida Crown Jewish Academy (Coed) www.icja.org 19 The Latin School of Chicago (Coed) www.latinschool.org 35 Loyola Academy (Coed)  www.goramblers.org 1 Marist High School (Coed)  www.marist.net 3 Mother McAuley Liberal Arts High School (G)  www.mothermcauley.org 8 Mount Carmel High School (B)  www.mchs.org 23 Nazareth Academy (Coed)  www.nazarethacademy.com 36 North Shore Country Day School (Coed) www.nscds.org 39 Northridge Prep School (B) www.northridgeprep.org 38 Notre Dame HS for Boys (B)  www.ndhsdons.org 14 Providence St. Mel School (Coed) www.psm.k12.il.us

c h icago area partners h ip sc h oo l s

5 Queen of Peace High School (G)  www.queenofpeacehs.org 34 Regina Dominican High School (G)  www.rdhs.org 33 Roycemore School (Coed) www.roycemoreschool.org 28 St. Benedict Preparatory High School (Coed)  sbhs.stbenedict.com 7 St. Francis de Sales (Coed)  www.sfdshs.org 13 St. Ignatius College Prep (Coed)  www.ignatius.org 24 St. Joseph High School (Coed)  www.stjoeshs.org

4 St. Laurence High School (B)  www.stlaurence.com 27 St. Patrick High School (B)  www.stpatrick.org 6 St. Rita of Cascia High School (B)  www.stritahs.com 25 Trinity High School (G)  www.trinityhs.org 9 The University of Chicago Laboratory School (Coed) www.ucls.uchicago.edu 40 The Willows Academy (G) www.willowsacademy.org

Class of 2018 application

Boarding S c h oo l s (Coed) - Co-Educational (B) - Boys (G) - Girls

Most boarding schools will accept the DMSF application as the application to their schools, so long as the application is submitted by DMSF directly to the boarding schools. Do not submit your DMSF application directly to any boarding school. Brooks School (Coed) www.brooksschool.org Cate School (Coed) www.cate.org Chatham Hall (G) www.chathamhall.org Cheshire Academy (Coed) www.cheshireacademy.org The Church Farm School (B) www.gocfs.net Concord Academy (Coed) www.concordacademy.org Culver Academy (Coed Military) www.culver.org Deerfield Academy (Coed) www.deerfield.edu Emma Willard School (G) www.emmawillard.org Episcopal High School (Coed) www.episcopalhighschool.org The Ethel Walker School (G) www.ethelwalker.org Fountain Valley School of Colorado (Coed) www.fvs.edu The Governor’s Academy (Coed) www.thegovernorsacademy.org Groton (Coed) www.groton.org The Hun School (Coed) www.hunschool.org Lake Forest Academy (Coed) www.lfanet.org LaLumiere School (Coed) www.lalumiere.org The Lawrenceville School (Coed) www.lawrenceville.org) Loomis Chaffee www.loomischaffee.org

Middlesex School (Coed) www.mxschool.edu Milton Academy (Coed) www.milton.edu Northfield Mount Hermon School (Coed) www.nmhschool.org Phillips Exeter Academy (Coed) www.exeter.edu The Putney School (Coed) www.putney.com Robert Louis Stevenson School (Coed) www.rlstevenson.org Shattuck-St. Mary’s School (Coed) www.s-sm.org St. George’s School (Coed) www.stgeorges.edu St. John’s Northwestern Military Academy (B) www.sjnma.org St. Mark’s School (Coed) www.stmarksschool.org St. Paul’s School (Coed) www.sps.edu Taft School (Coed) www.taftschool.org Thacher School (Coed) www.thacher.org Wasatch Academy (Coed) www.wacad.org Wayland Academy (Coed) www.wayland.org The Woodlands Academy - Sacred Heart (G) www.woodlandsacademy.org A cademic / R esidentia l P rograms

Mooseheart (Coed) www.mooseheart.org Boys Hope Girls Hope (Coed) www.chicagobhgh.org

Please note: The recommended deadline for students who are interested in applying to boarding school is

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Daniel Murphy Scholarship Fund

100 W. Monroe, Suite 500 • Chicago, IL 60603 • (312) 455 - 7800 100 W. Monroe, Suite 500 ◆ Chicago, IL 60603 ◆ (312) 455 - 7800 The mission the Daniel Murphy Scholarship Fund (DMSF) is to give high scholarship Themission mission assistance of M urphy Scholarship Fund (DM is to provide four-year high school school scholarships and assistance educational supThe of the theDaniel Daniel Murphy Scholarship Fund (DMSF) is to give high scholarships and and educational support toSF) students from economically disadvantaged port servicessupport to economically disadvantaged Chicago eighthdisadvantaged grade students who demonstrate DMSF academicseeks potential, in order to ensure educational to students from economically backgrounds. to make a life-altering backgrounds. DMSF seeks to make a life-altering difference in the lives of its Scholars by they are properly difference in the prepared lives of for its college. Scholars by providing them with the best opportunity to succeed in high school and providing them with the best opportunity to succeed in high school and college. college. Ask your teacher for an application or pick one up at DM SF’s office from 9 am to 5 pm.

The application can be downloaded on our website http://www.dmsf.org/become-a-dmsf-scholar The application can be downloaded on our website http://www.dmsf.org/become-a-dmsf-scholar

DMSF High School Fair DM SF D M S F Hig hHigh S cSchool h ooFair l F air Tuesday, October 8, 2013 Monday, October M onday, October 18,17, 20102011 5:005:00pm p.m. to 7:30 p.m. 7:30pm 5:00 pm toto6:15 pm SaintSaint Ignatius College Prep Ignatius College Prep Saint I gnatius College Prep 1076 Roosevelt Road 10761076 W.W. Roosevelt RooseveltRd. Rd. Chicago, IL60608 60608 Chicago, IL Chicago, IL 60608 is fair an opportunity meet representatives moreabout aboutDM DMSF’s partnership is an opportunity to meet representativesfrom fromand and learn learn more about SF’s partnership highschools. schools. TheThe fairfair isThe an opportunity to to meet representatives from and learn more DMSF’s partnership high schools. CTA Blue

CTA Blue

CTA Blue

CTA Blue CTA Red

W Harrison St

S Michigan Ave

S Wabash Ave

P

W Roosevelt Rd

S State St

S LaSalle St



S Canal St

Saint Ignatius College Prep

S Clinton St

S Paulina St

W Taylor St

University of Illinois at Chicago

S Halsted St

W Polk St S Morgan St

S Racine Ave

Pink

S Ashland Ave

CTA Blue

Red

CTA Orange Green

We advise families to take public transportation to this event. Contact CTA for alternate routes: 312-836-7000. We advise families to take public transportation to this event. Contact CTA for alternate routes: 312-836-7000.

A l lDeadline: comp Application Deadline:l eted app l ications must b e postmar k ed Application Eighth students DM SF Boarding are encouraged an applicationto by or considering deapplications l i v ered tomust D MSchools S be F no l ater ttohsubmit andelivered Allgrade completed postmarked or Friday, October 15, 2010. F riday, O cto b er 2 5October , 2 0 1 3 28, 2011. DMSF no later than Friday,

All The completed applications must for be postmarked delivered to DM SF no later recommended deadline students whoorare interested in applying tothan boarding school is Friday, October 29, 2010.

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