Las Vegas Southwest Rotary Club
Academic Scholarship
Application Form
The Las Vegas Southwest Rotary Club will award one $9,600 Academic Scholarship to a
graduating senior for the academic year 2009-2010 that intends to attend UNLV, UNR,
CCSN or other Community College in Nevada. The $1,200 scholarship will be awarded
on a per-semester basis and is renewable for up to 8 semesters of college as long as the
applicant maintains a 3.0 GPA (on a 4.0 GPA maximum) and completes a minimum of 12
semester hours per semester.
Required eligibility requirements:
1. Graduating from a Northwest Accredited high school in Clark
County, Nevada.
2. A minimum weighted or non-weighted 3.5 GPA.
3. Demonstrate a family or student financial need.
Desired eligibility requirements:
1. A minimum composite ACT score of 25 or a SAT score of
1200, a student selecting to attend CCSN will be exempt from
this requirement.
2. Demonstrate leadership in school and/or community.
3. Must be a legal resident of the United States
To apply please complete the scholarship packet by May 01, 2010:
1. Application form
2. A recent photo
3. Financial need statement
4. Seven semester official transcript, including recent national test scores
5. A 750 word essay on the topic “My accomplishments during my high
school years”
Submit your completed application packet to:
Troy Lochhead
2500 North Buffalo Suite 150
Las Vegas, Nevada 89128
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Las Vegas Southwest Rotary Club
Academic Scholarship
Application Form
STUDENT INFORMATION
Name of applicant __________________ __________________ ____
Last First M.I.
Social Security Number _______________________
Address __________________________________________
__________________ ________________ ______
City State ZIP Code
High School of Enrollment_____________________________________
Parent or Guardian ____________________Relationship___________
Address __________________________________________
(if different from applicant)
__________________ ________________ ______
City State ZIP Code
Home phone __________________
Business phone __________________
Please list all post high school institutions that you have applied to:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
_____________________________________ _________________
Signature of Applicant Date
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Las Vegas Southwest Rotary Club
Academic Scholarship
Application Form
Student Profile
Community Service – list the volunteer work you have completed during
high school. Indicate the service organization and what you did.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Leadership in high school – list all positions you have held including the
year. You can describe what you did in those leadership roles.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Awards and Honors – list all that you have received in high school and
indicate what your grade level was when the award/honor was received.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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Las Vegas Southwest Rotary Club
Academic Scholarship
Application Form
Financial Statement
Parent or guardian of applicant:
__________________ __________________ ____
Last First M.I.
Occupation ___________________ Employer ____________________
Parent or guardian of applicant (other parent or guardian if working):
__________________ __________________ ____
Last First M.I.
Occupation ___________________ Employer ____________________
Adjusted Gross Income from most recent Tax Return_____________
(attach copy of the 1st page of Form 1040)
Other income source towards your college expenses:
(include scholarships you have been awarded)
Amount ___________ Source _________________________________
Amount ___________ Source _________________________________
Are there other members of your family currently attending college?
_____________
Yes / No
Number of children in your family, including applicant ____________
Please add any information you feel will strengthen your candidacy for
this scholarship.
____________________________________________________________
____________________________________________________________
____________________________________________________________
_______________________________ _________________
Parent or guardian signature Date
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Las Vegas Southwest Rotary Club
Academic Scholarship
Application Form
For School Official Use Only
Rank in Class ________ Number in Class _________
GPA cumulative _______ GPA weighted ___________
SAT Scores ___________ ______________
Verbal Math
ACT Score ___________
_______________________________________________
Signature of School Official and Title
Please attach the Official seven-semester transcript here.
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