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SECTION 1: STUDENT INFORMATION
Name*
First Last
Permanent Mailing Address*
Street Address City State ZIP Code
Date of Birth*
Date field description.
Age*
Number field description
High School*
Student ID #*
Home Phone*
Cell Phone
Email*
Gender*
- Male
- Female
- Prefer not to answer
Racial, Cultural or Tribal Background
Country of Birth
City of Birth*
State of Birth*
I confirm that I am a*
- US Citizen
- Permanent Legal Resident
Permanent Resident #*
Issue Date*

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SECTION 2: PARENT / GUARDIAN INFORMATION
Please tell us about your Mother*
- I have information about my Mother
- I do not have information about my Mother
- My Mother is deceased
Mother's Name*
Mother's Marital Status*
Mother's Occupation / Job Title
Mother's Employer
Highest Education Completed*
College
Degree
Was the degree earned outside of the United States?
- Yes
- No

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Please tell us about your Father*
- I have information about my Father
- I do not have information about my Father
- My Father is deceased
Father's Name*
Father's Marital Status*
Father's Occupation / Job Title
Father's Employer
Highest Education Completed*
College
Degree
Was the degree earned outside of the United States?
- Yes
- No

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SECTION 3: ADDITIONAL HOUSEHOLD INFORMATION
What is your first language?*
How often is English spoken at home?*
- Always
- Occasionally
- Rarely or Never
Including yourself how many people live in your home?*
How many siblings do you have?*
Please complete the following fields for each of your siblings.
1. Name
Age
Do they live at home?
- Yes
- No
Have they attended college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
2. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
3. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
4. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
5. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
6. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
7. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
8. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
9. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
10. Name
Age
Lives at home?
- Yes
- No
Been to college?
- Yes
- No
College Name
Degree
Has the degree been completed?
- Yes
- No
Please list all other people living in your home.
Name Age Relationship

Use the little "plus sign" (+) to the right of the row to add more rows.

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SECTION 4: FAMILY INCOME
Financial need is based on the income of the person or persons you lived with most during the past 12 months.

We will need copies of the first 2 pages of the 2017 1040, 1040A or 1040EZ Federal Tax Form. If parent or guardian is self-employed, please also include Schedule C.

Please provide the Federal Tax Forms to your school's Simon Scholar Liaison.
Did your parent(s) or guardian file taxes last year?*
- Yes
- No
Are your parent(s) or guardian exempt from filing taxes?*
- Yes
- No
Some individuals may not be required to file income taxes if their income is below the taxable threshold. The threshold amount depends on one's age, type of income and filing status. Learn more on the IRS website.
To the extent that you are able and comfortable, please explain why taxes are not filed.*
Some reasons taxes are not filed include:
    • Income is below the filing requirement
    • Active Duty Military Service
    • Serious Illness
    • Death in Immediate Family
    • Destruction of Records
    • Incarceration
Do they file their taxes separately or jointly?*
- They file separately
- They file jointly
Adjusted Gross Income*
Please enter the tax filer's Adjusted Gross Income (AGI). This amount is listed on
    • Line 37 on Form 1040
    • Line 21 on Form 1040A
    • Line 4 on Form 1040EZ
Second Parent's Adjusted Gross Income*
Please enter the tax filer's Adjusted Gross Income (AGI). This amount is listed on
    • Line 37 on Form 1040
    • Line 21 on Form 1040A
    • Line 4 on Form 1040EZ
Does your family receive financial payments in the form of child support, alimony or social security?*
- Yes
- No
Please state the monthly amount received and from whom.*
Monthly Amount Received From
Has your family income changed significantly in the past year?*
- Yes
- No
Please explain.*

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SECTION 5: STUDENT INVOLVEMENT
High School Extracurricular Activities
Such as Clubs, Sports, Music, Arts, etc.
Activity From (mm/yy) To (mm/yy)
Community Involvement during High School
Such as Volunteer Service, Church, Tribal Activities, Performance, etc.
Activity From (mm/yy) To (mm/yy)
Honors and Awards Received during High School
Please list the most recent first.
Honor / Award Year Received
Cumulative GPA*
Please choose the range that reflects your cumulative GPA including grades from the Fall of your Sophomore year.
If your Cumulative GPA is below 3.0, please contact your school liaison to see if you are eligible to apply to the program.
Are you, the applicant, currently employed?*
- Yes
- No
Where do you work?
How many hours per week do you work?

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SECTION 6: SHORT-ANSWER ESSAYS
As we consider your Simon Scholars application, we highly value your reflections on your strengths and struggles, perspectives and experiences. Please respond to the following essay questions. Your responses should be approximately 500 words (3000 characters) each and in essay format, not bullet points.

Remember that you may type your answers directly into the response area or you may copy and paste your essays from your previously saved document.
Question 1
Briefly share with us a personal challenge you have faced and the ways in which you worked through this. What internal strengths or external resources helped you overcome this challenge? What did you learn from this experience?
Response*
Question 2
What are your goals and aspirations for the future, and how would participation in the Simon Scholars Program help you reach these goals?
Response*
Question 3
Our scholars share a common dedication to performing well in school and earning a college degree. Aside from this, tell us what you are most passionate about. This may include an activity, a hobby, a goal, a cause, a belief…
Response*
Please share anything that might help us know you better and understand your life circumstances, living situation, and/or academic performance.

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SECTION 7: APPLICANT CERTIFICATION AND RELEASE OF INFORMATION
Have you ever been subjected to disciplinary action during middle school or high school, such as probation, suspension or dismissal?*
- Yes
- No
Please explain.*
Have you ever been detained or adjudicated for a delinquent act?*
- Yes
- No
Please explain.*
The Simon Scholars Program is an intensive participatory program that requires committing extra personal time to week nights, weekends and overnight events scheduled throughout the year.
Can you and will you agree to participate fully and to the best of your ability?*
- Yes
- No
Are there any activities or conflicts that will prevent you from participating in our summer retreat, Saturday tutoring, or overnight events?*
- Yes
- No
Please explain.*
I certify that I have provided complete and accurate information. I further certify that all documents are authentic and unaltered. I authorize the SFPS/APS School District to release my student records, including transcripts, to the Foundation and Selection Committee. I understand that I must notify the Foundation of any change in my full-time school enrollment or application status. I further declare that if I am selected as a Simon Scholar, I will continue to attend a Certified Simon Scholar High School and commit to participating in all Foundation events, acting as a role model and abiding by the Simon Scholar minimal GPA requirements. I understand that if I am found to be in violation of any of these requirements, my scholarship could be jeopardized. I certify that I have discussed this application with a parent or guardian and have their permission to share this information with you and to participate in this program, if selected.
Student Signature*
Using your mouse, stylus or finger, please sign this application.

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NEW MEXICO SIMON SCHOLARS
Empowerment through self-discovery, exploration, and education.

Step 1 of 9

SECTION 1: STUDENT INFORMATION

SECTION 2: PARENT / GUARDIAN INFORMATION

SECTION 3: ADDITIONAL HOUSEHOLD INFORMATION

SECTION 4: FAMILY INCOME

SECTION 5: STUDENT INVOLVEMENT

SECTION 6: SHORT-ANSWER ESSAYS

SECTION 7: APPLICANT CERTIFICATION AND RELEASE OF INFORMATION

Name	Age	Relationship

Monthly Amount	Received From

Activity	From (mm/yy)	To (mm/yy)

Activity	From (mm/yy)	To (mm/yy)