Educational Assistance Grant Application

100 Club of Illinois Educational Assistance Application

Welcome to the 100 Club of Illinois Educational Assistance Application. Please read the information below thoroughly before proceeding to the next steps.
Privacy & Disclosure

Providing information to the 100 Club of Illinois for all questions not marked as required is voluntary and will not be considered in your grant application review. The material gathered will be maintained confindentially and protected from misuse or modification. This data will be retained for club records and aggregated for reporting purposes. All shared reports will contain no identifiable personal content. Required items will be marked as much.
Application Eligibility
In order to be eligible for educational assistance, I understand I need to meet the following criteria in order to continue with this application:
- Be a biological child, step child, adopted child, or spouse of a 100 Club Fallen Hero
- Enrolled full-time at an accredited institution or university (minimum 12 hours for undergraduate, minimum 9 hours for post-graduate)
- Maintain a 2.0 GPA each term and cumulatively
- Have applied for ISAC or PSOEA funding assistance
- Meet age requirements
- Submit all required documentation needed by the 100 Club of Illinois
Next Steps

Once completed, this application will be valid for the entire school year. For example, if you apply in the fall for educational assistance, we will not ask you to re-apply until the following fall, unless you are graduating or any of your information has since changed (new school, new degree, address change, etc.)

You will receive a copy of this application once completed. After completion and approval, a second form will be sent to review your goals and plans for the term ahead. This is a bi-annual form that will need to be completed in the fall and spring term to confirm your progress towards your goals.

Questions

If you have questions about the application process, please contact:

Kaira Zaremba

Program Manager

kzaremba@100clubil.org

312-971-5806

Scholar Demographic Information
Scholar's Name*

First NameLast Name
Preferred Name (if different from above)
Scholar's Birthdate:*

MonthDayYear
Date
Gender:*

FemaleMaleNon-Conforming
Race (please check all that apply):*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
Primary Language:*
Scholar's E-mail*
example@example.com
Scholar's Phone Number*
Please enter a valid phone number.
The best way to contact me is by:*

E-mailPhone CallText MessageOther
Permanent Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Mailing Address (If this address is the same as your permanent address, you may leave this section blank)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Planned Living Arrangements*

On CampusOff Campus
My preferred address during the school year is my ________________. Mailings and checks if you choose to have them sent to you instead of your institution will be mailed here based on your selection.*

Permanent AddressSchool Address
I am currently*

EmployedNot Employed
Company and Job Title
Fallen Hero Information
I am a _____________ of a fallen hero:*

Biological ChildStepchildAdopted ChildSpouse
Name of 100 Club Hero*

First NameLast Name
Department and Title/Rank of 100 Club Hero*
Name of Surviving Parent*

First NameLast Name
Surviving Parent Email*
example@example.com
Surviving Parent Phone Number*
Please enter a valid phone number.
Annual Family or Household Income (Please note this is required if you are applying for the Larry J. Vincent Memorial Scholarship Fund further in the application)
Application and Financial Aid Information
Application Date*

MonthDayYear
Date
Is this your first time applying for educational assistance through the 100 Club of Illinois?*

YesNo
I am applying for the:*

Fall TermWinter TermSpring TermSummer Term
Have you applied for PSOEA (Public Safety Officer's Educational Assistance Program)? Please Note: In order to be eligible for PSOEA benefits, your family must first be approved by the Public Safety Officers' Benefits Program. For more information, visit www.psob.gov.*

Yes, and I've been approvedYes, and my application is pendingNo, I have not applied for PSOEA fundsI am not eligible for PSOEA funds
Have you applied for ISAC? Please Note: All scholars are required to apply for ISAC assistance, and proof of application status or award amount must be submitted with this application. If ISAC funding has been granted, the amount must be shown and verified by your school's Financial Aid office on the 100 Club Grant Financial Aid Form. The signature of approval on this form serves as your proof. If funding has been denied, please supply a copy of your determination letter. For more information and a list of ISAC approved Illinois institutions, visit: www.isac.org.*

Yes, and I have been approvedYes, and my application is pendingNo, I have not applied for ISAC fundsI am not eligible for ISAC funds
ISAC and PSOEA Status Document Upload

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If my application is approved, I would like my check to be mailed to:*

My permanent addressMy school addressDirectly to the financial aid officeI prefer to pick up my check from the 100 Club of Illinois
Institution Information
Name of Institution or University (Please note: The institution must be officially accredited at the regional or national level)*
What type of program are you enrolled in?*

Undergraduate (Pursuing Bachelor's Degree)Post-Graduate (Pursuing Master's or Doctoral Degree)Associates DegreeVocational or TradeFirst Responder AcademyOther
What is your current year of study?*

FreshmanSophomoreJuniorSeniorFirst year post-gradSecond year post-gradDoes not applyOther
Field of study/Major*
Name of degree or certificate*
School ID Number*
I am enrolled as a ____________ student. (Please note: All scholars must maintain full-time status to remain eligible for educational assistance)*

Full-timePart-time
I am enrolled in _____ credit hours this term, semester, or quarter*
Anticipated Month and Year of Graduation*
Financial Aid Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Financial Aid Officer*

First NameLast Name
Estimated Expenses
Tuition*
Mandatory Fees*
Deadline of Tuition and Fees Payment*

MonthDayYear
Date
Please note: The 100 Club can provide financial assistance for the following expenses, in addition to the above educational expenses. Please only include answers for items for which would like to receive financial assistance. Copies of receipts/invoices must be submitted via e-mail to Kaira Zaremba at kzaremba@100clubil.org for each item to be considered.
Books
Rent
Utilities
Other Fees
What would these other fees cover?
Additional Questions
Are you in need of an internship related to your field of study?

YesNo
Are you in need of a mentorship related to your field of study?

YesNo
Are you in need of resume support?

YesNo
The 100 Club of Illinois offers a Buddy Program that begins each school year. The Buddy Program gives an opportunity for you to be matched with another scholar so the two of you can connect, offer support and encouragement, and possibly build a friendship throughout the year.
Would you like to be involved with the Buddy Program?

Yes, connect me with a buddyNo, I'm not interested
The 100 Club of Illinois also provides get togethers, activities, and other opportunities to meet other scholars throughout the year! If you have any suggestions or feedback for this coming year, please let us know below.
Please provide suggestions or feedback for the scholar program, if any or any additional information that would be helpful to know with your application:
Please upload any tuition statements, receipts, or supporting documentation if you have it ready, if not, please e-mail directly to kzaremba@100clubil.org no later than two weeks prior to your tuition deadline.

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Larry J. Vincent Memorial Fund

Scholars Attending Private Institutions
You may be eligible to receive the Larry J. Vincent Memorial Scholar Financial Stipend of up to $2,500 annually for text books. This scholarship is awarded during the fall semester.

Please Note: The request for family income shown previously on this application is optional and strictly for reporting purposes. However, if you wish to be considered for the Larry J. Vincent Memorial Stipend, submitting this information is required. The scholar will be selected according to the highest outcome of the following ratio:

Gap in Funding for Tuition, Room, & Board

_______________________________________

Family Income

This information will not be reviewed as part of your 100 Club Educational Assistance Grant Application and will only be considered in the Larry J. Vincent Memorial Scholar selection process.
Would you like to apply for the Larry J. Vincent Memorial Fund?

YesNo
Agreement
I First Name* Last Name* certify that I am the biological child, adopted child, step child or spouse of a law enforcement officer, firefighter or EMS provider whose family qualified for assistance from the 100 Club of Illinois and was, at the time of the fatality, dependent upon such officer, firefighter or EMS provider. I further certify that I will promptly notify the 100 Club of any change in my status, school or course of study, and that any funds received from or through the 100 Club as a result of this application will be used by me and only in furtherance of my educational pursuits. I agree to complete the planned course of study for the term for which this grant may be awarded. I understand that I must maintain my status as a full-time student and a GPA of or above 2.0 to remain eligible for educational assistance. I certify that all information contained in this application is true and correct to the best of my knowledge. I understand the 100 Club may verify any and all information submitted and any misrepresentations may result in an immediate rejection of this application. I understand that providing my signature in the below field will serve as my official signature and certify the accuracy of the information I have provided in this application.
Signature*

Clear
Should be Empty:

100 Club of Illinois Educational Assistance Application

Scholar Demographic Information

Fallen Hero Information

Application and Financial Aid Information

Institution Information

Estimated Expenses

Additional Questions

Larry J. Vincent Memorial Fund

Agreement