The John T. and Ada M. Diederich Educational Trust Award Application

Character/Service

Name Date First

Middle Last

Home Address

City Zip

Home Phone # High School

Award Objective To seek eligible high school seniors who desire to pursue a college degree and who have

demonstrated outstanding character and promise as evidenced by work ethic and service to

others.

Basic Requirements for Consideration of an Applicant

• Applicant must have resided for the past three years in one or more of the

following Kentucky counties: Boyd, Carter, Greenup, Lawrence, or

Martin. No exceptions.

• Applicant must present a cumulative grade point average, computed as of

the end of the first semester of the year of application, of between 2.25

and 3.55. No exceptions.

• Applicant must present an ACT score of 17 or higher.

• ACT score must be received before initial interview.

Application Information Your financial need is NOT a basis for granting an award nor is the affluence of your

family a basis for denying an award.

• No person associated with an applicant's high school or who is personally acquainted

with an applicant is permitted to be involved in the review of that applicant or in the

award decision regarding that applicant.

• Applicant must personally complete this application in his/her own handwriting, unless

applicant is physically disabled.

• Provide accurate information as all information is subject to verification.

Academic Information GPA on a 4.0 scale ACT Score Date ACT was taken

College Information I have applied to college I Have not applied to college

College or University to which you have applied or plan to apply

Estimated cost per year (include room/board/tuition/books)

1

Financial Aid Information I have filed the FAFSA . I have not filed the FAFSA

Employment Information List any jobs you have had. Please include the phone number of your boss or supervisor.

Employer Dates Employed Supervisor Phone #

/ / /

/ / /

/ / /

/ / /

I I /

School Activities in which you have engaged Name of Activity School Year Offices Held

/ /

/ /

/ /

/ /

/ /

/ /

Other Activities in which you have engaged Name of Activity

/

School Year Offices Held

/

/

/

/

/

/

/

/

/

/

/

Self Evaluation of Activities What activities have you found to be the most rewarding or challenging?

2

Self-evaluation of Academic Record How do you feel about your academic performance?

Social Behavior Have you ever been suspended or expelled from school? Yes _No

Have you ever received in-school suspension? _Yes No

Have you ever been convicted of a crime? Yes No

If you answered yes to any of the above questions, please explain.

Attendance Record Number of days absent in each grade:

Please explain any frequent absences

9th,

10th, 11 th, 12th

Statement of Applicant: In your own words, define character. Why is character important

to your community? Why should your character be considered exceptional?

3

Service Record: Discuss any activities that you feel demonstrate your commitment to

serving others. Include the names of individuals and organizations that received the

service.

Terms and Conditions of Application I have read and understand this application. To the best of my knowledge, the information contained herein is true and

complete. The Management Committee has my permission to contact the schools, relatives, employers or other persons

named in this application or such other sources as the Management Committee may deem necessary for consideration of

an award to me. I understand that any of the information I have presented may be verified by outside sources. I

understand any information contained herein discovered to be false or deliberately misleading will result in the removal of

this application from consideration. If I am granted an award, I authorize the university/college I attend to release my

grades each semester to the Management committee for the purpose of ascertaining my continuing eligibility for the

Diederich Award.

Name Date If applicant is under 18 years of age, one parent or guardian must sign approving the terms and conditions of this

Application for Award.

Parent/Guardian Date

4

Faculty Recommenders

To the Recommender: We request that you sign this form indicating that you have filled out a Recommendation Form for

this student; however, individual forms will remain anonymous.

Student's Name

High School

Name Date

Subjects Taught

The John T. and Ada M. Diederich Educational Trust

DIEDE RICH AWARD

Recommendation Form

Student's Name

Date

High School

To the Recommender: We request your help with evaluations of the characteristics listed below. Responses should be based

on comparison with other students you have known. Any comments that you believe would be important to our understanding of your rating should be noted in the column on the right. Additional remarks may be placed on the back of the sheet.

Diederich Awards are made on the basis of outstanding character and not on the basis of test scores, grade point averages, or financial need. Thank you for your assistance in helping us identify the select group of Diederich Award Winners.

Characteristics

Truly Extraordinary (Upper 2%)

Outstanding (Upper 10%)

Good (Upper 25%) Average

Below Average

No Opportunity to Observe Please Comment

Work Ethic, Attitude

Completes Undertakings

Willingness to Help Others

Truthfulness, Honesty

Ability to Respond

Appropriately to Criticism

Willingness to Try,

Perseverance

Ability to Get Along with

Others

Leadership Qualities

Please comment on the student's potential to realize his/her ambitions or goals

Please use the back of the sheet for any additional comments

We request that you sign the attached Recommenders' list indicating that you have filled out a

Recommendation Form, however, individual forms should remain anonymous.

The John T. and Ada M. Diederich Educational Trust

DlEDERACH AWARD

Recommendation Form

Student's Name

Date

High School

To the Recommender: We request your help with evaluations of the characteristics listed below. Responses should be based

on comparison with other students you have known. Any comments that you believe would be important to our understanding of your rating should be noted in the column on the right. Additional remarks may be placed on the back of the sheet.

Diederich Awards are made on the basis of outstanding character and not on the basis of test scores, grade point averages, or financial need. Thank you for your assistance in helping us identify the select group of Diederich Award Winners.

Characteristics

Truly Extraordinary (Upper 2%)

Outstanding (Upper 10%)

Good (Upper 25%) Average

Below Average

No Opportunity to Observe Please Comment

Work Ethic, Attitude

Completes Undertakings

Willingness to Help Others

Truthfulness, Honesty

Ability to Respond

Appropriately to Criticism

Willingness to Try,

Perseverance

Ability to Get Along with

Others

Leadership Qualities

Please comment on the student's potential to realize his/her ambitions or goals

Please use the back of the sheet for any additional comments

We request that you sign the attached Recommenders' list indicating that you have filled out a Recommendation Form, however, individual forms should remain anonymous.

The John T. and Ada M. Diederich Educational Trust

DIEDERICH AWARD

Recommendation Form

Student's Name

Date

High School

To the Recommender: We request your help with evaluations of the characteristics listed below. Responses should be based

on comparison with other students you have known. Any comments that you believe would be important to our understanding of your rating should be noted in the column on the right. Additional remarks may be placed on the back of the sheet.

Diederich Awards are made on the basis of outstanding character and not on the basis of test scores, grade point averages, or financial need. Thank you for your assistance in helping us identify the select group of Diederich Award Winners.

Characteristics

Truly Extraordinary (Upper 2%)

Outstanding (Upper 10%)

Good (Upper 25%) Average

Below Average

No Opportunity to Observe Please Comment

Work Ethic, Attitude

Completes Undertakings

Willingness to Help Others

Truthfulness, Honesty

Ability to Respond

Appropriately to Criticism

Willingness to Try,

Perseverance

Ability to Get Along with

Others

Leadership Qualities

Please comment on the student's potential to realize his/her ambitions or goals

Please use the back of the sheet for any additional comments

We request that you sign the attached Recommenders' list indicating that you have filled out a

Recommendation Form, however, individual forms should remain anonymous.