Welcome to

St. Dominic High School

Jan L. Schultehenrich
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:_________

All applicants for this scholarship must fill out and return the PSAS Student Aid form. Go to SDHS website
www.stdominichs.org, click PSAS form and print. Or form may be obtained from school office.

PART I - SHOULD BE SENT TO ST. DOMINIC
PART II – SHOULD BE SENT TO THE COMPANY (PSAS).

____ I have mailed my PSAS Student Aid form on ________________. (fill in date mailed)

____ Current GPA (Minimum of “C” required)

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

2. 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. Explain briefly your financial need for this scholarship.

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