Lake Mills Rotary Scholarship

2012

LAKE MILLS ROTARY SCHOLARSHIP

GENERAL INFORMATION

Students Name (First, Middle Initial, Last) / Telephone (Area/No.)
Students Address (Street, City, ZIP)
School Name / No. of Students in Grade / Student’s Rank
School Address (Street, City, ZIP) / Cumulative GPA / ACT/SAT Score
Parent’s or Guardian’s Name
Parent’s or Guardian’s Address (Street, City, ZIP)

College Attending: ______Major: ______

Address: ______

Anticipated Costs (Per Semester):Anticipated Costs (Per Year):

Tuition:$______Tuition:$______

Room and Board: ______Room and Board: ______

Books: ______Books: ______

Transportation: ______Transportation: ______

Other Expenses (Identify): ______Other Expenses (Identify): ______

Attach a copy of the student’s transcripts as the final document of the completed nomination package (after the Letters of Recommendation.)

SIGNATURES

I CERTIFY that the applicant is a student in good standing and demonstrates probable success in post-secondary education.

Signature of High School Principal or Counselor / Date
Signature of Student / Date

ATHLETICS

Please check which years you have participated in the following activities (including interscholastic and intramural activities).

Freshman

/ Sophomore / Junior / Senior
Baseball/Softball:
Basketball:
Cheerleading:
Cross Country:
Football:
Golf:
Gymnastics:
Soccer:
Swimming:
Tennis:
Track and Field:
Volleyball:
Wrestling:
Other:Please Specify:

Individual Sport Achievement/Special Recognition:
Please list individualtitles (conference, regional, sectional, state, team captain, etc.) you have won.

______

Describe the value of participating in these athletic activities to you andothers.

______

MUSIC AND SPEECH RELATED HOBBIES, OUTSIDE INTERESTS, SPECIAL TALENTS

Please check which years you have participated in music and speech-related activities.

Freshman

/ Sophomore / Junior / Senior
Orchestra:
Band:
Chamber:
Voice:Choir:
Solo:
Theater: Musical Production:
Drama:
Dance: Please Specify:
Speech:
Forensics:
Debate:
Other Activities:Please Specify:

Individual Achievement: Please list contest awards (regional, conference or state recognition, team captain, etc.) you have won.

______

Hobbies/Outside Interests/Special Talents:

______

OTHER SCHOOL, CIVIC AND COMMUNITY ACTIVITIES

Please list all school activities in which you have participated while ingrades 9-12. Indicate the number of years in the appropriate space. In addition, if you have held office in any organization, so indicate along with any special honors, awards or recognition received. Activities included on this page are activities not listed on pages 2 and 3.

School Activities /

Freshman

/ Sophomore / Junior / Senior /

Office Held/Honors/Recognition

Please list specifically what you did for the club or activity while you were a member.

______

Please list all civic and community activities in which you haveparticipated while in grades 9-12.

Community and Civic Activities / Number of Months of Participation

Freshman

/ Sophomore / Junior / Senior

Describe the value of participating in these activities to you andothers.

______

WORK EXPERIENCE

Work Experience (paid or unpaid)

Senior Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Summer Employment between Junior and Senior Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Junior Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Summer Employment between Sophomore and Junior Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Sophomore Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Summer Employment between Freshman and Sophomore Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

Freshman Year:

Employer /

Duties

/ Hire Date / Quit Date / Hours Worked Per Week

STUDENT ESSAY

Name of Nominee: ______

Please answer all five essay questions (Attach another sheet if necessary. If typewritten, please double-space.)

1.When do you perceive yourself as being successful with your career/job?

2.What does Rotary mean to you and this community?

3.Of all the service organizations, which one interests you the most and why?

1. What type of community service, if any, do you plan to do after college?

At what point in your life do you plan to do this, if any?

1. What would you be comfortable doing in giving back to your community?

LETTERS OF RECOMMENDATION

To the student: This page may be duplicated and given to those who will bewriting a letter on your behalf. Please submit two letters of recommendation, one from EACH of the following categories:

1. Teacher, neighbor, member of religious community.

2. Employer.

Both recommendation letters must be attached to your application.

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Guidelines for Recommendation Letter:

To enhance a student's nomination for a Scholarship, it is helpful to have specific examples of noteworthy improvements, contributions, or successes in an area or areas such as scholarship, leadership, citizenship, school activity and service to the community. You may also address attributes such as honesty, cooperation, integrity, acceptance of responsibility, positive attitude, initiative, compassion, entrepreneurship, etc. Please limit your letter to one page. Your letter must accompany the student's application form.