2025 Application — Lilly Scholarship | Community Foundation of Randolph County

2025 Lilly Endowment Community Scholarship Program Application

"*" indicates required fields

Personal Data

Name*

First Middle Last

Permanent Mailing Address*

Street Address Address Line 2 City State ZIP Code

County of Residence

Date of Birth*

Phone*

Cell Phone*

Email*

Scholastic Profile

High School Name*

High School Address*

Street Address Address Line 2 City State ZIP Code

Select Your High School Counselor*

Graduation Date*

What is your high school rank?*

SAT Score*

ACT Score*

Parent(s) / Guardian(s) Name and Relationship to Applicant*

Parent(s) / Guardian Cell Phone Number*

List the 4-Yr Indiana College(s) or University(s) you have or intend to apply to & indicate whether or not you have been accepted.*

What is your major course of study? If undecided, indicate areas of interest.*

EXTRACURRICULAR ACTIVITIES, AWARDS, HONORS, COMMUNITY, CIVIC, CHURCH ACTIVITIES, AND WORK HISTORY

List your extracurricular activities.*

Activity

If you held a leadership position, please list or enter "No."

Grade

Number of weeks

Hours per week spent in each activity

Please note: You do not need to list the same thing under multiple sections, just put it under the section that it best fits.

List all awards & honors over past 4yrs.*

Award or Honor

Grade

List all community, civic, and church activities and work history. (This does not have to be a paid position.)*

Activity/Work History

Grade

Number of weeks

Hours per week spent in each activity

DOCUMENTS TO UPLOAD

GOALS AND ASPIRATIONS

Describe your educational goals including plans for your career and future. Be sure to answer this question in your response; How would this scholarship impact your goals and aspirations? 250 words or less double spaced,1-inch margins, using Calibri (body) 11 font.

Goals and Aspirations*

Drop files here or

Max. file size: 25 MB.

Upload one double spaced document with 1-inch margins, using Calibri (body) 11 font in 250 words or less.

SELF EXPRESSION ESSAY

Describe what makes you unique and special. This portion is designed for you to elaborate on topic(s) that uniquely make you, you. Please do not include financial information. Upload up tp 2 pages, double spaced, 1-inch margins, using Calibri (body) 11 font.

SELF EXPRESSION ESSAY*

Drop files here or

Max. file size: 25 MB.

Upload up to 2 pages, double spaced document, 1-inch margins, using Calibri (body) 11 font.

THREE SIGNED LETTERS OF RECOMMENDATION (From someone other than a relative.)*

Drop files here or

Max. file size: 25 MB.

THESE MUST BE SIGNED BY THE RECOMMENDER (Any letter received without a signature will not be accepted)

Application Checklist*

Student application

3 Signed Letters of Recommendation

Self Expression Essay

Goals & Aspirations

Lilly Endowment Community Scholarship Program Certification Statements

The Lilly Endowment Community Scholarship Program requires students to acknowledge the following statements.

“IF I RECEIVE THIS SCHOLARSHIP, IT IS MY INTENT TO PURSUE FOUR YEARS OF UNDERGRADUATE STUDY ON A FULL-TIME BASIS LEADING TO A BACCALAUREATE DEGREE AT AN INDIANA COLLEGE.”

“I UNDERSTAND THAT THE TOTAL MAXIMUM AMOUNT OF MY SCHOLARSHIP IS CALCULATED ON THE BASIS OF MY CHOSEN COLLEGE’S TUITION AND REQUIRED FEES BEGINNING WITH THE 2024-2025 SCHOOLYEAR.”

“I UNDERSTAND THAT THE SPECIAL ALLOCATION PROVIDED TO ME IS TO BE USED TO PAY REQUIRED BOOKS AND REQUIRED EQUIPMENT FOR MY COURSES OF INSTRUCTION. I WILL PERSONALLY KEEP RECEIPTS AND OTHER DOCUMENTATION TO VERIFY THAT THE SPECIAL ALLOCATION WAS USED ONLY FOR THIS INTENDED PURPOSE AND WILL PROVIDE THOSE RECEIPTS AND DOCUMENTS TO INDEPENDENT COLLEGES OF INDIANA UPON REQUEST AND I WILL RETURN TO INDEPENDENT COLLEGES OF INDIANA ANY AMOUNT OF THE SPECIAL ALLOCATION REMAINING AT THE END OF EACH SCHOOL YEAR.”

“I AGREE TO NOTIFY INDEPENDENT COLLEGES OF INDIANA OF ANY SCHOLARSHIP AWARDS I MAY RECEIVE FOR TUITION OR REQUIRED FEES FROM A SOURCE OTHER THAN THE LILLY ENDOWMENT COMMUNITY SCHOLARSHIP.”

Lilly Statements Acknowledgement*

I acknowledge that I have read and understood the Lilly certification statements by placing my initials in the space provided above.

Community Foundation of Randolph County, Inc. Certification Statements

CFRC, Inc. requires students to acknowledge the following statements.

“TO ASSIST WITH THE PROCESSING OF MY SCHOLARSHIP PAYMENTS EACH SEMESTER OR QUARTER AND TO AVOID LATE FEES, I WILL FORWARD TO THE COMMUNITY FOUNDATION OF RANDOLPH COUNTY IMMEDIATELY UPON RECEIPT, ALL INVOICES FOR TUITION AND ANY ELIGIBLE FEES THAT MAY BE COVERED BY MY SCHOLARSHIP.”

“I WILL KEEP THE COMMUNITY FOUNDATION OF RANDOLPH COUNTY, INC. APPRISED ANNUALLY BY JUNE 1ST OF MY ENROLLMENT AND ACADEMIC STATUS DURING COLLEGE, BY COMPLETING AND RETURNING ANY SURVEYS OR FORMS AS MAY BE PROVIDED BY THE COMMUNITY FOUNDATION.”

“UPON GRADUATION, I WILL KEEP THE COMMUNITY FOUNDATION OF RANDOLPH COUNTY APRISED ANNUALLY BY JUNE 1ST OF MY EDUCATION AND/OR EMPLOYMENT STATUS FOR AT LEAST TEN YEARS AFTER GRADUATION, BY COMPLETING AND RETURNING AN ALUMNI SURVEY OR OTHER FORMS AS MAY BE PROVIDED BY THE COMMUNITY FOUNDATION.”

“I AM NOT A LINEAL DESCENDENT (CHILD OR GRANDCHILD) OF ANY CURRENT DIRECTOR, BOARD MEMBER, STAFF OR SCHOLARSHIP COMMITTEE MEMBER OF THE COMMUNITY FOUNDATION OF RANDOLPH COUNTY, INC.”

“I AGREE TO NOTIFY THE COMMUNITY FOUNDATION IMMEDIATELY OF ANY OF THE FOLLOWING”

TRANSFER FROM ONE COLLEGE TO ANOTHER FOR ANY REASON
NON COMPLETION OF A SEMESTER OR A YEAR
THE POTENTIAL OF A SEMESTER AWAY FROM CAMPUS DUE TO INTERNSHIPS, OR STUDY ABROAD. (SCHOLARSHIP AWARD CONTINUATION IS DETERMINED ON A CASE BY CASE BASIS)

“I FURTHER UNDERSTAND THAT ANY RULINGS TO THE SCHOLARSHIP AWARDED BY INDEPENDENT COLLEGES OF INDIANA SHALL BE DEEMED ABSOLUTE AND FINAL.” “IN SUBMITTING THIS APPLICATION I CERTIFY THAT THE INFORMATION PROVIDED IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. FALSIFICATION OF INFORMATION MAY RESULT IN TERMINATION OF ANY SCHOLARSHIP GRANTED.”

Community Foundation of Randolph County, Inc. Acknowledgement*

I acknowledge that I have read and understood the CFRC certification statements by placing my initials in the space provided above.

CODES OF CONDUCT

Enter your initials to acknowledge and agree to each code of conduct.

I understand that my character and conduct at any time prior to and after the selection process may impact my eligibility to become or remain the recipient of the Lilly Endowment Community Scholarship.*

Enter your initials to acknowledge and agree with the code of conduct #1.

I understand my character & conduct, at any given time, is vital for the LECSP.*

Enter your initials to acknowledge and agree with the code of conduct #2.

I authorize CFRC, educational institutions, employers, entities or individuals, to release & exchange information about me including, but not limited to, my academic history, grades, disciplinary record, character & ethical qualifications. This authorization specifically includes any required authorization under FERPA (Family Educational Rights & Privacy Act).*

Enter your initials to acknowledge and agree with the code of conduct #3.

I understand CFRC will not take any action based on unconfirmed information or information provided by anonymous sources.*

Enter your initials to acknowledge and agree with the code of conduct #4.

APPLICANTS SIGNATURE: “I have reviewed this application & determined that it is correct & complete. I further promise to attend the banquet on September 25th at 6pm and the interviews scheduled for October 3rd if I am invited to do so.”*

Date*

PARENT/GUARDIAN SIGNATURE - “I have reviewed this application and have determined that it is correct & complete.*

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