Ken Kubsch Scholarship - Application

Dr. Ken Kubsch, grew up in Kellnersville, Wisconsin where he graduated from Manitowoc’s Lincoln High School. He graduated from Marquette School of Medicine in 1968.

Known simply as “Kenny”, he was a very caring and humble family and internal medicine doctor. He simply loved people, regardless of position, status, or income. His smile and laugh were infectious, and his focus was always on brightening your day, never on himself.

Kenny never passed up an opportunity to educate those around him and had such an enthusiasm for learning.

The Ken Kubsch Scholarship will commemorate Kenny’s life. It will be a presented annually to a student who is interested in history or science, both passions of Kenny, as well as exemplifies the selfless and compassionate nature of Ken Kubsch.

Please make sure your high school is eligible for this scholarship.

Name

First Name

Last Name

Middle Initial

Phone

(###)

###

####

Email Address

General email address that will be used after High School

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SCHOOL INFORMATION

Grade Point Average (GPA) - High School

Number of Students in Class

Rank in Class or Laude Points

List in chronological order all schools attended in the last four years, including any summer or special courses.

Include - Name of school / Location (city) / Dates of Attendance

List any academic distinction or honors you have earned and the grade levels in which you earned them (9, 10, 11, 12)

ACTIVITIES

Note those activities in which you have been actively engaged (organizations, sports, or clubs) and which you feel have been most meaningful to you (include years of participation, grade, levels, and any offices held)

WORK EXPERIENCE

List employment you have held in the past three or four years

Position / Employer / During the Summer or School Year / Dates / Number of Hours Per Week

HIGHER EDUCATION AND PUBLIC SERVICE

If applicable, the College or University you have been accepted to

What field of study?

Anticipated enrollment date

YYYY

Have you been awarded (or reasonably expect to receive) other grants or scholarships?

Yes

If yes, please list the name of the scholarship and the amount you will receive below

FAMILY INFORMATION

Parents: (Check if living)

Mother

Father

Stepmother

Stepfather

Legal guardian

Number of Children in Family

If you have siblings, number who will be in college

ESSAY

Write a statement of NO MORE THAN 500 WORDS discussing your goals, what you consider to be your strong points, and why this scholarship should be awarded to you.

REFERENCES

Letters of reference are not required. However, at least one reference and no more than two references of the applicant’s choice should be named. The selection committee reserves the right to contact these references. References cannot be family members or peers.

Include - Name / Phone #

DUE DATE

Please submit by March 27th unless stated differently guidance office

SIGNATURE

I certify that all the above information is true to the best of my knowledge.

Type name below

Today's Date

YYYY