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Amy Dickherber 
Memorial Scholarship 
St. Dominic High School
31 St. Dominic Drive
O’Fallon, MO   63366

							Social
Student’s Name: ________________________________	Security: ________________________
Street Address:  __________________________________________ Phone:  ____________________
City:____________________________________       State:  _________    Zipcode: _______________
Parent’s Name:		  Father:____________________              Mother: ____________________
Parent’s Daytime Number:  Father:____________________              Mother: ____________________
									Number of
In what parish is your family registered? _______________________________ 	Children: _________
School student attends presently :    _________________________________  Grade:_________
Student applicant should answer the following questions:
1.	What academic areas have you most enjoyed in the current or more recent school year and why?





2.	What occupation interests you as a possible career choice and why?





3.	List extra-curricular activities (organizations, sports, clubs, etc.), community, parish or other service activities you have been involved with in the last two years.  What has this meant for you?
Extra-curricular:  
In the Community:
In the Parish:
Other Activities:

4.             What part does music play in your life and how does it influence you? (use extra sheet if needed)





THIS FORM SHOULD BE COMPLETED AND RETURNED BY TUESDAY, MARCH 25, 2008 TO:
Amy Dickherber Memorial Scholarship
St. Dominic High School
31 St. Dominic Drive
O’Fallon, MO   63366