Fillable 2022 Holley MUSIC Scholarship Instructions And Application Fillable

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2022 Holley MUSIC Scholarship Instructions And Application Fillable

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Mark Stockwell, CPA, CPFO, Executive Director
12444 Powerscourt Drive, Suite 500, St. Louis, MO 63131
office: 314-800-2220 | cell: 636-346-9949
mark.stockwell@musicprogram.org
DIRECTORS
Chairman
Dr. Bernard DuBray
Fort Zumwalt R-II School District
110 Virgil St.
O’Fallon, MO 63366
(636) 240-2072
Vice-Chairman
Dr. Phil Cook
Carl Junction R-I School District
206 S. Roney
Carl Junction, MO 64834
(417) 649-7026
Secretary
Dr. Chris Wilson
Kennett #39 School District
1400 West Washington
Kennett, MO 63857
(573) 717-1100 ext. 103
Treasurer
Mr. Ron Orr
Pattonville R-III School District
11097 St. Charles Rock Rd.
St. Ann, MO 63074
(314) 213-8005
Director
Mr. Todd Galbierz
St. Charles Community College
4601 Mid Rivers Mall Dr.
Cottleville, MO 63375
(636) 922-8359
Director
Dr. Jeanette Cowherd
Park Hill School District
7703 NW Barry Road
Kansas City, MO 64153
(816) 359-5904
Director
Dr. Tracy Bottoms
Montgomery Co. R-II School District
418 N. Hwy 19
Montgomery City, MO 63361(573)
564-2278
Director
Mrs. Jenny Ulrich
Lonedell R-XIV School District
7466 Hwy FF
Lonedell, MO 63060
(636) 629-0401
Director
Mr. Jeff Blackford
Nodaway-Holt R-VII School District
318 South Taylor St.
Graham, MO 64455
(660) 939-2137
Dr.Darrell"Jack"Holley/MUSICScholarship
The Missouri United School Insurance Council (MUSIC) encourages you to apply for the Dr.
Darrell "Jack" Holley/MUSIC Scholarships. The funding of the scholarships is provided by
proceeds from the golf tournament and corporate donations.
Dr. Darrell “Jack” Holley was MUSIC’s first Executive Director. As a school business official
with the Mehlville School District and president of MOASBO, he worked with the Arthur J
Gallagher Company and others to create the MUSIC Program in 1985. Jack served as the
Executive Director for twelve years developing/enhancing coverages, expanding services
and growing the program to include close to 400 school districts, community colleges and
educational associations before retiring. We are all very proud of Dr. Holley and honored to
provide these scholarships in his name. You can still see Jack at the MUSIC-MOASBO Golf
Tournament held each May, playing and telling stories of how it all started.
MUSIC members are designated into three enrollment size categories: small, medium and
large. Six scholarships (two in each category) of $2,000.00 each (nonrenewable) will be
awarded to 2022 graduating seniors of districts that are MUSIC members.
The following guidelines will govern the scholarship program.
1. The public high school you attend must be in a district that is a current member of
MUSIC, unless a K-8 district nominates you.
2. Only ONEapplication from each high school is to be submitted.
3. The application form must be postmarked by February 18, 2022. Late applications will
not be considered.
4. All applications must be (typed) printed. No handwritten applications will be
considered.
5. A copy of your official high school transcript (based on seven semesters) including your
ACT or SAT score needs to accompany your application.
6. Your application packet should include a letter of recommendation from a district
administrator, counselor or teacher (submit only one (1) letter).
7. The recipients will be posted on the MUSIC website (http://www.musicprogram.org) by
April 8, 2022.
8. The scholarship will be sent directly to the recipients once proof of paid college tuition
is provided.
Send completed application packets to:
MarkStockwell,ExecutiveDirector
MUSIC
12444PowerscourtDrive,Suite500
St.Louis,MO63131
ATTN:ScholarshipApplication
Dr. Darrell "Jack" Holley/MUSIC Scholarship
APPLICATION
Send completed application packets to:
MUSIC, Attn: Scholarship Application, 12444 Powerscourt Dr., Suite 500, St. Louis, MO 63131
Rev. 11/21 Page 1
I. PERSONAL INFORMATION
Name:
Last First Middle
Address:
Street
City State Zip
Telephone: Email Address:
Parent(s)/Guardian(s) Name:
II. SCHOOL DISTRICT INFORMATION
High School Currently Attending
*School District:
Address:
Street
City State Zip
Telephone:
*NOTE: If you are being nominated by a K-8 district, indicate this district:
School District Size: Small (0-499) Medium (500-2,000) Large (Over 2,000)
(***Use the total K-12 district enrollment as reported in the 2020-21 Missouri School Directory***)
III. CAREER PLANS
Name and address of the college or institution you plan to attend:
Name:
Address:
Street
City State
Zip
Intended major or career path:
Explain your planned program of study, career objectives and educational goals:
IV. ACADEMIC INFORMATION (based on seven semesters)
Rank #: in a Senior class of students.
ACT Score: SAT Scores: W M CR
List honors or awards you have received:
DEADLINE for all
application material:
February 18, 2022
No handwritten applications will be considered.
Dr. Darrell "Jack" Holley/MUSIC Scholarship
APPLICATION
Send completed application packets to:
MUSIC, Attn: Scholarship Application, 12444 Powerscourt Dr., Suite 500, St. Louis, MO 63131
Rev. 11/21 Page 2
V. SCHOOL ACTIVITIES
List the activities you participated in while in high school:
VI. LEADERSHIP
List any offices you have held or other positions of leadership:
VII. COMMUNITY ACTIVITIES / SERVICE
List the community activities and services in which you have participated:
Dr. Darrell "Jack" Holley/MUSIC Scholarship
APPLICATION
Send completed application packets to:
MUSIC, Attn: Scholarship Application, 12444 Powerscourt Dr., Suite 500, St. Louis, MO 63131
Rev. 11/21
Page 3
VIII. STATEMENT FROM THE STUDENT
(In your essay, address why you think you deserve the Holley/MUSIC Scholarship and what makes you unique. Tell us
something about yourself that is not already evident in the application.)
Print Name: Student’s Signature:
CERTIFICATION: The information in the application is correct and this student is scheduled to graduate:
Princi
pal or Superintendent’s Signature:
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2022 Holley MUSIC Scholarship Instructions And Application Fillable

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Completed 1 December 2021

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