~2017~

Lakeville Rotary Scholarship

Application

Lakeville Rotary "Service Above Self" Scholarship

Due March 17, 2017

Student Name (print): ______

Student’s High School (circle): LNHS LSHS

Student's Dean (print): ______

The Lakeville Rotary "Service Above Self" Scholarship will be awarded to a student who best represents the spirit and ideals of Rotary International. The award will be based upon the student's history of leadership andcommunity involvement, charitable efforts, overcoming obstacles, entrepreneurship, attitude, future plans and need.

CERTIFICATION AND SIGNATURES

All of the information on this form is true and completed to the best of my (our) knowledge. We agree to give proof of the information we provided on this application. If selected, the High School and/or the Lakeville Rotary Club may include recipientin anylocal scholarship publicity releases.

Applicant’s Signature:______

Parent/Guardian Signature: ______

EDUCATIONAL INFORMATION

Educational History

Elementary School(s):______

Middle School(s):______

Senior High School(s):______

Post Secondary (PSEO): ______

College, University, or Military Service Intentions

Program of study/major: ______

College attending(if known): ______

1st Choice: ______

2nd Choice: ______

Write one or two paragraphs describing your future career aspirations. Be sure to explain your motivation for choosing this career path and how the Rotary Scholarship award would help you attain your goal. (Use the back of this sheet if additional space is needed.) ______

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Describe your involvement as a leader or volunteer in charitable or service organizations, and how your efforts helped others.

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Please provide your employment history. Make note of any special recognition or successes.

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Please describe your involvement in school related activities. Make note of the extent of your involvement and any special recognitions:

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Please describe any special challenges or circumstances you have faced in your life and how you tried to overcome them:

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SECTION IV RECOMMENDATION LETTER

Applicants are encouraged to submit onerecommendationletter with this application.The letter can come from a teacher, employer, clergyperson or other person who is familiar with you and your accomplishments. Be sure to make your recommendation letter request 2 weeks in advance of the deadline. The completed letter should bereturned to you. Applicant should bring their letter,(paper clipped) withthis application, to the Career Center. Do not deliverthe letter to the Career Center without thisapplication.

SECTION VI FINANCIAL INFORMATION

The Financial Reportsection does not needto be completed unless the applicantwishes to be

considered for scholarshipswhere alevel of financial needisa requirementfor receiving an award. All information provided remains in the strictest confidence within the selection committee, and destroyed after the recipient selection process has been completed.

INCOME, EXPENSES, AND ASSETS FOR THE YEAR OF: ______

Please have your parent(s) fill in the following section. Information is based on IRS form 1040, or current income estimates if prior to filing last year’s tax return.

1. Adjusted Gross Income:$______

2. Income earned from work by: Father:$______

Mother:$______

3. Non-taxable income: Social Security Benefits,

Child Support, Welfare, other:$______

4. Medical/Dental expenses not paid by insurance: $______

5. Cash, savings, bonds, stocks, checking accounts,

certificate of deposits, notes, etc.:$______

6. Number of exemptions:#______

Additional Information:

Parents’ current marital status: _____Single _____Married _____Divorced _____Widowed

Total number of family members who will be attending a post-secondary school at least half time during the upcoming school year, includingapplicant: ______

Remark on any special conditions not reflected in previous sections.

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