February 7, 2015
Dear ESL Contact and School Counselor,
For the fourteenth year, the Virginia ESL Supervisors’ Association is proud to be able to offer
scholarships to ESL students who are planning to continue their studies at an institution of higher
The VESA Scholarship Application form is attached. You may duplicate the application as
necessary. Please encourage your ESL teachers and school counselors to assist students in gathering the
required documents so that all applications will be complete at the time of mailing. The deadline for all
applications is April 4, 2015.
The following criteria will be used for scholarship consideration:
Enrolled in an ESL program for at least one year in grades 6-12 in a Virginia public school
Enrolled in 12th grade at the time of application
3.0 minimum cumulative grade point average
Financial need
Please note the importance of a local contact person taking the time to assist the student in
completing ALL sections of the application. Due to the large number of applicants last year, the
committee will not be able to personally follow-up on sections of the application that are missing.
We hope to be able to announce the names of the scholarship winners no later than
May 15, 2015.
If you have any questions, please feel free to contact me at (540) 662-3889, Ext. 88145 or via
email at restivos@frederick.k12.va.us
Silvia Restivo, Ed.D., LPC
Coordinator of School Counseling and ESL Services
Frederick County Public Schools
1415 Amherst Street
Winchester, VA 22601
(540) 662-3889 ext. 88145
FAX (540) 722-3025
Student Information (Return by April 5, 2015)
Full name (including middle):_
Street Address:
City and Zip Code:
Email Address:
Date of Birth:
Country of Birth:
High School (currently enrolled):
High School Address:
Dates of Attendance at this High School:
Rank:___GPA:_____ Highest SAT scores: Critical Reading:____Math:_____Writing:_____ACT:____
U.S. College(s) to which you have applied to ____________________________________________
Been accepted to_______________________ Plan to attend ________________________________
Intended major/field of study: __________________Career Goal:_____________________________
List your school activities (or attach separate sheet): __________________________________
List your community service activities (or attach separate sheet): ___________________________
Contact Person for School
Preferred ESL teacher or school counselor:
Parent Information
Parents’ names____________________________________________________________________
Parents’ address___________________________________________________________________
Financial Information
Family gross income for year 2014 ______________
Number of brothers/sisters 21 years old or younger living at home: _____ or are in college ____
Please list any scholarships/grants you have applied for and/or received:
Name and amount: ____________________________________________________________

The following items must be enclosed in the VESA Scholarship Application packet:
 A copy of ALL high school transcripts available
 Two letters of recommendation from teachers, school counselor and/or principal at the school in
which student is enrolled
 This completed application form with attachments for questions 1-3 below
Your responses to the following statements will be considered in the selection process. Your responses
to items 1-3 should be typed.
1. Give a brief summary of your life, telling what you would like others to know about you. Be sure to
include any extraordinary events that have helped to shape your life. (maximum 300 words)
2. Describe your personal and educational goals, and tell how the scholarship money would be used to
help you meet your goals. If you have been accepted at a university or college, please indicate where.
(maximum 300 words)
3. Please list any other information that you think might be helpful for the selection committee. For
example, list clubs, sports, hobbies, jobs, volunteer work or other similar activities. Also list any honors
or awards you have received.
I certify that the information contained in this application and the accompanying documents is true,
complete, and correct to the best of my knowledge.
__________________________________________ _________ _
(Signature of applicant) (Date)
__________________________________________ ___________________
(Signature of ESL teacher or guidance counselor) (Date)
Return completed application to: (Remember to include all items requested)
Silvia Restivo, Ed.D., LPC
Coordinator of ESL Programs and School Counseling Services
Frederick County Public Schools
1415 Amherst Street
Winchester, VA 22601
Return by April 4, 2015