Willowbrook Rotary Foundation Scholarship - ClubRunner

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					          Willowbrook Rotary Foundation Scholarship
                  Fall 2012 Application Form

I _________________________, will graduate from Klein, or Cy Fair ISD in spring 2012
and plan to begin my college education starting with the fall semester of 2012.

I understand that this scholarship award is for two academic years with payments of $625
per semester beginning with the fall semester of 2012 for a maximum of $2,500.

 I understand that applicants must have overcome challenges either academic or social, be
willing to discuss these challenges, and have a current GPA of at least 2.5 (on a 4.0 scale). In
addition to completing this application form I understand that I must attend an interview by the
Willowbrook Rotary Selection Committee (“Selection Committee”) on May 12, 2012.

I understand that in order to accept this award I must attend an accredited local two year
college. I also understand that if I do not enroll in the fall of 2012, I will relinquish this entire
scholarship award.

I understand that maintaining my eligibility requires achieving a 2.5 GPA, completing a
minimum of 9 hours for each fall and spring semester and attending at least one
Willowbrook Rotary meeting or function per semester.

Note: All completed scholarship application forms must be received by May 3, 2012.

(Student Information)

Student’s Full Name__________________________________________________________

Name of High School _________________________________________________________

Student’s Home Address: Street ________________________________________________

                             City & Zip Code_________________________________________

Home Phone Number _______________ Cell Phone Number ________________________

Student’s e-mail Address ___________________________

Have you applied for admission to a trade school or two year college? ________

List school(s) where you have applied.____________________________________________

Have you been accepted? __________

Student’s Signature & Date _____________________________________________________
Student Financial Information (To be kept strictly confidential)

Indicate your family’s IRS adjusted gross income for 2011: _______________

Do you contribute to your family income by paying any of your car, insurance, or personal
expenses? __________ If yes how much per year ___________

Do you contribute to your family income in any other manner? __________If yes, please
explain: ___________________________________________________________________

Indicate the number of individuals (including parents and dependents) in your household ___

How many of these individuals will be enrolled in college or trade school in the fall 2012
semester? (Including applicant) __________

If you work (outside the home) how many hours per week do you work? __________

What type of work do you do? ___________________________________________________

Who do you work for? __________________________________________________________

How much is your income? (Hourly or per year) ______________________________________

List one work reference and telephone number: ______________________________________

List any other scholarships, loans or financial aid you have or will apply for and indicate if you
have been accepted:


(Student Activity Information)

Please list up to ten (10) volunteer, community, and school sponsored activities you participated
in during high school:


Essay Section, Completed only by the student and attached to the application
Note: there are two essay requirements; (a) career aspirations and (b) challenges

(a) In your own words describe your career goals, intended major in two-year College.

(b) In your own words describe academic and/or social challenges you have overcome.
(Principal/Counselor Provided Information)

Student: All information above to be included and given to your Principal/Counselor for
completion and submittal. The information below is to be filled out and signed only by your
Principal/Counselor. This application will not be accepted without the required information,
validated and signed.

Student GPA (adjusted to a 4-point scale): ____Please provide a transcript with this application

Indicate if the student’s GPA is weighted for honors or other advanced classes (yes/no).

Indicate if the student's GPA has been impacted by a social or personal event (yes/no). If yes,
please discuss:


Principal/Counselor, please give your reasons why this applicant should be chosen:








Signature of Principal or Counselor and title:

__________________________________________ Date: _____________________________

Principal/Counselor: The completed application, including essays, is to be returned to
the Willowbrook Rotary Club, Attention: Patricia Fraske, 5914 Old Lodge Drive,
Houston, TX 77066. Note: All completed scholarship application forms must be
received by May 3, 2012.

Willowbrook Rotary Club will consider all applicants and selection of the recipients is at
the sole discretion of its Selection Committee. The Selection Committee bases its
decision solely on the responses on the application and the personal interview.

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