Berkely Rotary Scholarship Application

BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

DUE APRIL 10, 2012

Please fill in your “Name” in the Top Header so it appears on every page.

Please either email this document to

or mail it to

Scholarship Committee

Berkeley Rotary Club

P.O. Box 11706

Berkeley, CA 94712-2706.

This application covers all Berkeley Rotary and the YMCA Scholarships.

Personal Information

Full Name ______

First Middle Last

Date of Birth: ____/____/_____ Place of Birth: ______

City State / Country

Permanent Home Address: ______

Street Number / Name

______

City / State Zip Code

Home Phone ______Cell Phone______

EMAIL: ______

We will contact you by email unless you request otherwise.

Alternative Contact______

Family Information

Parent / Guardian ______Relationship ______

Address(if different than yours) ______

Parent/Guardian ______Relationship ______

Address (if different than yours)______

Total Number of people in household in which you live including yourself ______

Primary language spoken at home? ______

Do you have immediate family members who have or are attending college? □ Yes□ No

If yes: College(s)? ______

Dates of attendance ______

Did he/she graduate? ______

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

Educational Data

High School currently attending ______

Dates of Attendance ______

Other High School(s) attended ______

Dates of Attendance ______

Classes Enrolled in this Semester ______

______

Contact Information of High School Counselor/ College Advisor

Name______Phone ______

E-mail ______

High School GPA ______

SAT Scores: Verbal ______Math ______Writing ______ACT Scores: Composite ______

What languages other than English do you read, write or speak competently?

______

I am a Berkeley YMCA Y- Scholar □ Yes □ No

Dates of Participation in the Y-Scholars Program ______

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

College/University Choices

Name and address of school(s) forwhich Scholarship is desired

1st Choice ______Accepted? ______

______Visited? ______

Location

2nd Choice: ______Accepted? ______

______Visited? ______

Location

Why have you selected the school(s) listed?
1st Choice______
______

2ndChoice ______

______

Proposed major field of study ______

______

Brief statement concerning the career for which you are preparing: ______

______
______

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

Activities, Employment and Experiences

In what social, athletic, political or other activities have you engaged? ______

______

To what organizations do you belong? ______

______

Briefly describe your involvement and explain why these activities have been important to you.

______

Employment Starting with your most recent job, list three jobs you have held. Indicate whether you werepaid or volunteered your services. Please indicate employer, dates employed, hours worked per week. If you have not yet worked or volunteered, please say so.

1) ______

□ Paid ______Hours per week □ Volunteer ______Hours volunteered per week

Responsibilities: ______

2) ______

□ Paid ______Hours per week □ Volunteer ______Hours volunteered per week

Responsibilities: ______

3) ______

□ Paid ______Hours per week □ Volunteer ______Hours volunteered per week

Responsibilities: ______

Personal Statement Write a personal essay. What is important for us to know about you? Tell us about how your background, experiences and efforts have shaped you as a person. You may want to write about your personal history, a challenge or obstacle you have faced or continue to face, or your goals and dreams. Tell us why you want to go to college and what you hope to learn there. What have you learned in high school? Who or what has helped you develop into the person you are today? What do you want us to remember about you?

Please type your answer, maximum two pages; put your name on the top of each page.

Essay Question Why do you think you would be a good investment for the Berkeley Rotary Scholarship? What will you have to offer your community upon graduation?

Please type your answer, maximum one page; put your name on the top of the page.

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

Personal Financial Information

Who currently supports you financially?

□ Parent(s) □Step-parent □Legal Guardian □Self □ Other______

If you are working - how many hours per week? ______Monthly income ______

I have$______in cash, savings, checking or other account (s).

Check which applies to you:

□ Attached is a copy of the Federal 1040 income tax return I have filed or will file for 2011

□ Attached is a copy of my 2010 Federal 1040 income tax return AND my 2011 W-2 form.

□ I did not file a 2010 income tax return and will not file a 2011 return.

Family Financial Information

My parent(s), step-parent or legal guardian’s occupation(s)

______

My parent(s), step-parent or legal guardian owns a home and/or property. □ Yes □ No

My parent(s), step-parent or legal guardian owns their own business. □ Yes □ No

Check which applies:

□ Attached is a copy of my parent(s) /guardian’s Federal 1040 income tax return for 2011

□ Attached is a copy of my parent(s) /guardian’s 2010 Federal 1040 income tax return

plus their 2011 W-2 forms

Briefly explain any financial circumstances affecting your ability to attend college that is not set out above.

______

Do you have a computer and appropriate software for college? □ Yes □ No

If NO please explain. ______

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

Estimated Expenses for the School Year

Name of College / University 1st Choice ______2nd Choice______

A) School Expenses

Tuition$______$______

Fees$______$______

Room, Board $______$______

Books $______$______

Personal$______$______

Travel$______$______

TOTAL School Expenses (A)$ ______$ ______

B) Sources of Funding

Self$______$______

Parent/Guardian 1$______$______

Parent/Guardian 2$______$______

Other Income$______$______

Vacation work $______$______

College / university job$______$______

Loans$______$______

TOTAL Sources of Funding(B)$______$______

C) Scholarships & Grants:other than Rotary

List all grants, College/University Scholarships,

applied for or that you intend to apply for.

Name:______$______$______

TOTAL Scholarships, Grants

Received (other than Rotary (C) $______$______

Assistance Needed (A - B -C) $ ______$ ______

Indicate if additional scholarships or grants that have been applied for have been

approved or received by placing a check mark after the amount.

Please check the College’s / University’s policy regarding outside scholarships.

Many institutions have limitations on aid received.

CHECK LISTof DOCUMENTS REQUIRED

for a COMPLETE SCHOLARSHIP APPLICATION

____1.Transcript of high school record. . A non-certified copy is acceptable with the application; a certified copy of the transcript is required prior to April 24th.

____2.Letters of recommendation

A)Letter of recommendation from a high school teacher who taught applicant

within the past two years.

B)Letter of recommendation from a counselor, employer, mentor, coach or

other knowledgeable adult.

C) Sealed letters of recommendation may be submitted by the applicant

or mailed directly to Berkeley Rotary by the recommender

____3.Offers of financial aid from colleges or universities you have selected.

____4.Copy of the SAR (Student Aid Report) or if not received

____5. Copy of FAFSA (Free Application for Federal Student Aid)

____6.Federal tax returns as checked. (Your tax return, your parent/guardian’s tax returns)

____7.Personal Statement

____8.Essay question

Applications should be presented single-sided, typed or hand printed.

Only complete applications will be considered. Keep a copy of your application.

All papers, letters, items listed above are to be sent to:

The Rotary Club of Berkeley

Post Box 11706

Berkeley, CA 94712-2706,

Attention: Scholarship Committee

Applications may be submitted electronically to:

We certify that the information given in this application is complete and accurate to the best of our knowledge.The foregoing financial information represents a true picture of financial needs.

______

(Signature of ScholarshipApplicant) (Date)

______

(Signature of Parent or Legal Guardian} (Date)

______

(Signature of Parent or Legal Guardian} (Date)

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

SCHOLARSHIP RECOMMENDATION FORM

DUE APRIL 10, 2012

Instructions for Scholarship Applicant

Fill in your name at the top of the next two pages and this instruction sheet.

Give these 3 pages to the person who will be completing this recommendation.

This recommendation is to be completed by an adult [not a relative] who knows you

well(a teacher,coach, club advisor, church or community leader, employer, mentor).

You may submit the completed recommendation in a sealed envelope with your scholarship application.

Instructions for Recommender

The Berkeley Rotary Scholarship is a four-year scholarship. The scholarship will be awarded based on demonstrated financial need, academic and personal achievement and where the committee believes this award can make a significant difference.

We are looking for students who will succeed in college but high academic achievement is not the most critical criteria. We are looking for students with much to offer their communities and who need the extra support that Berkeley Rotary can provide.

We need your help.Your recommendation is an important part of the application process. You may return the envelope to the applicant to submit with the rest of theirscholarship application.

You may also mail your recommendation. Mail it yourself to the address listed at the

top of this instruction page,

The completed recommendation must be postmarked by April 10, 2012.

If you have questions, please callBerkeley Rotary (510) 841-2319. This is our number at Direct Line Answering Service. We will have a member of the scholarship committee return the call. Please give the best times to call.

You may also email us at hank you

All scholarship information is CONFIDENTIAL and will not be shared with

anyone other than members of the Berkeley Rotary scholarship committee.

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

STUDENT NAME: ______

(Please print)

Your Name / Position______

Organization / Position ______

Email: ______Phone: ______

Mailing Address: ______

QUESTIONS:

How long have you known the applicant? In what capacity (coach, mentor, teacher, employer, etc)? Has he/she changed over that time? If so, how?

What is his/her most striking personality characteristic?

2.Is this student ready for the challenges and demands of college? We are looking for specific examples of the student’s readiness for rigorous college work, and ability to overcome obstacles and potential to be a leader.

Recommendation Page 1 of 2

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BERKELY ROTARY SCHOLARSHIP APPLICATION

Name: ______

2012 ROTARY SCHOLARSHIP RECOMMENDATION FORM

3.Have you seen the applicant respond to challenging academic or personal issues? Do you know how the applicant responds to new experiences or stressful situations?

4.Is there a reasonable expectation that Rotary’s investment will be justified? Please explain.

Is there anything else we should know about the applicant?

You may use a separate page if necessary.

______

(Signature of Recommender) (Date)

Recommendation Page 2 of 2

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Applicant’s Name ______

SCHOLARSHIP RECOMMENDATION FORM

DUE APRIL 10, 2012

Instructions for Scholarship Applicant

Fill in your name at the top of the next two pages and this instruction sheet.

Give these 3 pages to the person who will be completing this recommendation.

This recommendation is to be completed by an adult [not a relative] who knows you

well(a teacher,coach, club advisor, church or community leader, employer, mentor).

You may submit the completed recommendation in a sealed envelope with your scholarship application.

Instructions for Recommender

We need your help.Your recommendation is an important part of the application process. You may return the envelope to the applicant to submit with the rest of theirscholarship application.

You may also mail your recommendation. Mail it yourself to the address listed at the

top of this instruction page,

The completed recommendation must be postmarked by April 10, 2012.

If you have questions, please call Berkeley Rotary (510) 841-2319. This is our number at Direct Line Answering Service. We will have a member of the scholarship committee return the call. Please give the best times to call. Thank you.

You may also email us at hank you.

All scholarship information is CONFIDENTIAL and will not be shared with

anyone other than members of the Berkeley Rotary scholarship committee.

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Applicant’s Name ______

STUDENT NAME: ______

(Please print)

Your Name / Position______

Organization / Position ______

Email: ______Phone: ______

Mailing Address: ______

QUESTIONS:

How long have you known the applicant? In what capacity (coach, mentor, teacher, employer, etc)? Has he/she changed over that time? If so, how?

What is his/her most striking personality characteristic?

Recommendation Page 1 of 2

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Applicant’s Name ______

2012 ROTARY SCHOLARSHIP RECOMMENDATION FORM

3.Have you seen the applicant respond to challenging academic or personal issues? Do you know how the applicant responds to new experiences or stressful situations?

4.Is there a reasonable expectation that Rotary’s investment will be justified? Please explain.

Is there anything else we should know about the applicant?

You may use a separate page if necessary.

______

(Signature of Recommender) (Date)

Recommendation Page 2 of 2

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