Roadway Worker Memorial Scholarship Program Application Form

Roadway Worker Memorial Scholarship Program Application Form

On the road to a brilliant future

PURPOSE
The American Traffic Safety Services Foundation (ATSS Foundation) Roadway Worker Memorial Scholarship Program, awarded annually, provides financial assistance for post-high school education to the dependents of roadway workers killed or permanently disabled in work zone construction or maintenance activities within the work zone, including mobile operations and the installation of roadside safety features. Spouses of fallen workers and parents with custody or legal guardianship of surviving children are also eligible.
APPLICANT ELIGIBILITY REQUIREMENTS
Eligible applicants must be dependents of roadway workers killed or permanently disabled in work zone construction or maintenance activities within the work zone, including mobile operations and the installation of roadside safety features. Spouses of fallen workers and parents with custody or legal guardianship of surviving children are also eligible. The Manual on Uniform Traffic Control Devices (MUTCD) defines a work zone as an area of a highway with construction, maintenance or utility work activities. A work zone is typically marked by signs, channelizing devices, barriers, pavement markings and/or work zone vehicles. It extends from the first warning sign or high-intensity rotating, flashing, oscillating or strobe lights on a vehicle to the END ROAD WORK sign or the last temporary traffic control device.
AMOUNT OF SCHOLARSHIP
Each Roadway Worker Memorial Scholarship has a value up to $10,000*. If a particular applicant demonstrates a strong commitment to volunteerism, they may be eligible to receive an additional $1,000 in honor of Chuck Bailey, an esteemed member of the roadway safety industry who passed away in June 2002.

*Not to exceed the total qualifying costs of the institution.
EDUCATIONAL INSTITUTION REQUIREMENTS
The scholarship must be applied to a post-secondary school or institution that requires a high school diploma or General Educational Development (G.E.D certificate or diploma for admission. This could include any public or private: four-year accredited college or university; two-year accredited college; or vocational-technical college or a training institution.
SCHOLARSHIP SELECTION CRITERIA AND APPLICATION REQUIREMENTS
Applicants must provide a completed and signed Roadway Worker Memorial Scholarship Application Form and supporting materials to apply to the scholarship program. Applicants will be evaluated by the following four criteria:

1) Applicant’s past academic performance record of high school grades.

a. An official copy of the applicant’s transcript and grade report from the school currently being attended or most recently attended. The transcript should list all grade points earned and all academic coursework completed to date.

b. In the case of applicants already attending an institution of higher learning, their cumulative college grade point average (GPA) and academic performance will be considered.

2) Written essay that explains the applicant’s reasons for wanting to continue his or her education.

a. Essay should be typed, no more than 200 words, and written by the applicant.

b. Include any current volunteer activities/accomplishments.

c. Include current extracurricular activities of the candidate.

3) Demonstrated need for financial assistance for continuing education with a completed and signed Free Application for Federal Student Aid (FAFSA) form.

a. FAFSA form can be obtained online at studentaid.gov or from your high school guidance office.

4) Two letters of recommendation in support of the candidate’s application and the views expressed therein.

a. Letters may be from a teacher school administrator, counselor, member of the clergy or a supervisor who can address the applicant’s qualifications and academic aptitude.

b. Letters will NOT be accepted from immediate family members, other relatives, relatives by marriage or close family friends.

c. Letters must have a signature, date and contact information of person submitting/writing the letter(s).

d. Previous/repeat scholarship applicant letters cannot be a duplicate of one previously submitted.

Applicants must meet all the above requirements.

Roadway Worker Memorial Scholarship Program Application Form Navigating an academic path forward

APPLICATION DUE DATE
Applications and all required documentation must be received no later than Feb. 15. Applications received after Feb. 15 may not be considered. All applications and supporting materials will become property of the American Traffic Safety Services Foundation.
SCHOLARSHIP APPROVAL AND NOTIFICATION
Final approvals are granted by the American Traffic Safety Services Foundation Board of Directors at its sole discretion. All applicants will be notified in writing of the results of consideration by the Scholarship Review Committee. If selected, applicants must provide a recent photograph for use in promotion of the scholarship program.
SCHOLARSHIP YEAR AND AWARD DISBURSEMENT
The scholarship award year will be defined as the 12-month period specified in the award. Scholarship award money will be deposited by the American Traffic Safety Services Foundation with the university, college or institution of higher learning to which the student is admitted, accepted and which the student will attend.

The award money is credited to an account established in the individual’s name at the school. The funds can be used by the recipient for: fees or charges required for tuition; fees or charges for room and board while attending school; and expenses for textbooks, course work, lab fees and other materials as required by a course instructor (e.g., safety glasses, art/drawing supplies, glass slides, etc for required course assignments or projects.

Scholarship awards are non-transferable to another individual or institution and are forfeited by the recipient upon his/her withdrawal from the institution where the scholarship award was dispersed by the American Traffic Safety Services Foundation, or upon failure to meet the institutions appropriate standards of academic achievement, conduct or character.

If the recipient is diagnosed post-award by a Board-certified medical physician as having a chronic or acute illness or traumatic injury that makes it impossible for the recipient to enter or continue his or her academic studies, the scholarship award money will be held for the recipients’ academic use for up to 12 months. A letter from the physician to the American Traffic Safety Services Foundation must be received within 60 days of diagnosis.

In the event a scholarship recipient’s educational endeavors are interrupted during the award year because he or she is called to active duty under Title 10 of the United States Code or National Guard duty in state status, the scholarship award money will be held for the recipient by the American Traffic Safety Services Foundation for up to 24 months, unless the time for active duty is extended by the military authority.

Any scholarship award recipient leaving the U.S. Armed Forces or National Guard duty must reapply for reinstatement of the scholarship money or the remaining portion of the scholarship money within 90 days after severance from duty.
FOR SCHOLARSHIP INQUIRIES, CONTACT:
Director of ATSS Foundation

American Traffic Safety Services Foundation

15 Riverside Parkway

Fredericksburg, VA 22406-1077

Phone: 540-368-1701

Email: foundation@atssa.com

Roadway Worker Memorial Scholarship Program Application Form Navigating an academic path forward

EMPLOYER OR FORMER EMPLOYER INFORMATION OF THE DECEASED OR DISABLED
Please provide information about your deceased or permanently disabled parent, legal guardian or spouse’s employer or former employer. The ATSS Foundation will contact employer to verify incident.
Employer/Former Employer Name*
Contact Name*

First NameLast Name
Title*
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email
example@example.com
OTHER PARENT OR LEGAL GUARDIAN INFORMATION (IF APPLICABLE)
Name

First NameLast Name
Relationship to Applicant
Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number
Please enter a valid phone number.
Phone Number
Email Address
example@example.com
INTENDED COLLEGE OR INSTITUTION INFORMATION (IF KNOWN)
Name of Institution to which you will apply scholarship funds:*
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Website*
Have you been accepted for admission to this school?*
Which semester/year?*
What area of academic concentration will you pursue?*
If you are already in college, what is your cumulative GPA?*
Anticipated graduation date (month, year)*

MonthDayYear
Date
Estimated yearly tuition, room and board, and textbook expenses*
Upload your current transcripts. If you are a current high school student, upload your high school transcripts. If you are a current college student, upload your college transcripts. Official transcripts can be emailed to foundation@atssa.com*

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Applicant Essay:
Written essay that explains the applicant’s reasons for wanting to continue his or her education. Essay should be typed, no more than 200 words, and written by the applicant.
File Upload*

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On a separate document: list any academic, leadership, athletic or employment awards or recognition you have received and/or community activities or volunteer work you have participated in (include number of volunteer hours).*

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FAFSA Form:
Demonstrated need for financial assistance for continuing education with a completed and signed Free Application for Federal Student Aid (FAFSA) form. FAFSA form can be obtained online at studentaid.gov or from your high school guidance office.
File Upload

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Letters of Recommendation:
Two letters of recommendation in support of the candidate’s application and the views expressed therein.

a. Letters may be from a teacher school administrator, counselor, member of the clergy or a supervisor
who can address the applicant’s qualifications and academic aptitude.
b. Letters will NOT be accepted from immediate family members, other relatives, relatives by marriage or
close family friends.
c. Letters must have a signature, date and contact information of person submitting/writing the letter(s).
d. Previous/repeat scholarship applicant letters cannot be a duplicate of one previously submitted
File Upload*

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File Upload*

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Applicant Signature*

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Date*

MonthDayYear
Date
Should be Empty:

PURPOSE

APPLICANT ELIGIBILITY REQUIREMENTS

AMOUNT OF SCHOLARSHIP

EDUCATIONAL INSTITUTION REQUIREMENTS

SCHOLARSHIP SELECTION CRITERIA AND APPLICATION REQUIREMENTS

APPLICATION DUE DATE

SCHOLARSHIP APPROVAL AND NOTIFICATION

SCHOLARSHIP YEAR AND AWARD DISBURSEMENT

FOR SCHOLARSHIP INQUIRIES, CONTACT:

CONTACT INFORMATION AND ABOUT YOU

ACADEMIC HISTORY

DECEASED OR DISABLED INDIVIDUAL’S INFORMATION

EMPLOYER OR FORMER EMPLOYER INFORMATION OF THE DECEASED OR DISABLED

OTHER PARENT OR LEGAL GUARDIAN INFORMATION (IF APPLICABLE)

INTENDED COLLEGE OR INSTITUTION INFORMATION (IF KNOWN)

Applicant Essay:

FAFSA Form:

Letters of Recommendation: