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kiwanis            Scholarship Application

Sponsored by the Greater Plano Kiwanis Club

Please Type or Print Clearly

Name ____________________________________________________________________

 Address __________________________________________________________________

                     Street, City, St, Zip

Home Phone _________________          Cell Phone _____________________

Email Address ___________________________________________________

Date of Birth ____________________      Gender:  Male ______   Female ___________

Parent/Guardian Name(s) ______________________________________________________

Class Rank ______          Class size ________     Grade-point Average/Scale _____________

SAT Scores:  Verbal _______  Math  _______  Writing _________  Combined __________

High School ____________________________________________ ACT Score __________

Faculty Advisor Name ________________________________________________________

 UNIVERSITY INFORMATION

I have not finalized my decision as to which school I will be attending this fall:_________

I have applied, been accepted, and will be attending the following school:_________________

Scholarship funds will be mailed directly to the school’s Scholarship Office, please secure the address of this office)

University/School Name:________________________________________________________

Address:_____________________________________________________________________

____________________________________________________________________________

   City                            State                     Zip                                      Student ID#

 

List any reasons or special circumstances that should be considered for receiving this scholarship  (financial hardship, disability, single-parent household, etc.)

 ________________________________________________________________________________________

 ________________________________________________________________________________________   ________________________________________________________________________________________

 ________________________________________________________________________________________   List any/all elected or appointed offices in school organizations and year(s) of involvement:

 ________________________________________________________________________________________   ________________________________________________________________________________________

 ________________________________________________________________________________________   ________________________________________________________________________________________

 List any awards or recognition from school or school organizations:  

 ________________________________________________________________________________________  

 ________________________________________________________________________________________

 ________________________________________________________________________________________   ________________________________________________________________________________________

 List any/all jobs, summer employment or in-schoolwork (cafeteria, bookstore, etc)  

 ________________________________________________________________________________________

 ________________________________________________________________________________________   ________________________________________________________________________________________

 ________________________________________________________________________________________   Community Service, church, or charitable activities  

List any/all organizations you assisted with service and hours of service provided:  

 ________________________________________________________________________________________  

 ________________________________________________________________________________________   ________________________________________________________________________________________                                                                                   Page 2 of 3  

 _______________________________________________________________________________________

List any/all individual efforts of service to others, and hours served that were of your own initiative,  rather than as part of an organization or group.  Examples: assisting Kiwanis Angels, other youth athletics; assisting elderly person with housework, shopping visitations, etc; tutoring or mentoring a  younger student; or any civic activity to improve your community:

________________________________________________________________________________________

 ________________________________________________________________________________________

________________________________________________________________________________________  ________________________________________________________________________________________

List any special circumstances, disabilities, or situations that you had to overcome in order to succeed in   high school that would be an example to others of dedication and commitment to achieving a goal.    

Please be specific:

 ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________  ________________________________________________________________________________________

I hereby certify that all information provided in this application is true and accurate.  I fully understand   that forgery of any signature or intentional misrepresentation will result in the disqualification on my   

application and possible disciplinary proceedings.  

 ____________________________________              _________  

Applicant Signature                                                              Date                                  

 I hereby acknowledge that this applicant is a student in good standing at ___________________________  High School as of this date.

 _______________________________________              _________  Sub-School Principal or Counselor Signature                    Date  

I hereby acknowledge that this applicant is a Key Club member in good standing at__________________  High School as of this date. (if applicable)

 _______________________________________              _________

Key Club Faculty Sponsor                                                    Date                                   

Add extra sheets as necessary for your lists and details.

Mail the completed application to Greater Plano Kiwanis Club, P.O. Box 867046,    Plano, TX 75086-7046 or give to a Greater Plano Kiwanis Member        

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