Rotary Club of Barrie-Huronia
STUDENT
BURSARY APPLICATION
Name: ____________________________
Date of Birth:______________
SIN: _________________
Marital Status: ____________ Dependents _____
Permanent
Address: _____________________________________________
Phone: _________________Email:_______________________
Temporary
Address:________________Email:_______________________
Phone: _______________________
Academic
year applying for:________________
Name of
secondary school: _______________________________________
Year of
graduation: ______________ Final Year average _________
Name of
recent guidance counselor/teacher: ____________________
Name of
Post-Secondary institution: ___________________________
Program
of Study: ___________________________________
Expected
Year of completion: ________ Degree or diploma: ____________
Career
you hope to pursue:_____________________________
Estimated Expenses for Academic
Year
Total
tuition fee per year: ______________
Books,
tools, instruments: ______________
Residence/Room
and Board: ______________
Transportation: ______________
Other
(specify)
______________
Total Expenses: ______________
Financial Resources
Have you
applied for an
Amount of approved loan: _________
Grant: ____________
Name of all
scholarships/bursaries you will have or will receive: ____________
Sponsor:
_________________________Amount: _________________
Employment-- Part-Time
Seasonal Summer
Amount you expect to contribute
toward school costs ______________
Total
combined income of parents/guardians from the
previous tax
year (all sources): ______________
Number of dependents they support:
_________
Additional information related to
parents income/assets: ___________
________________________________________________________________________________________________________________________________________________
Please
list other significant assets ( > $1000 value ie: Car) ________________________
________________________________________________________________________
Other
sources of income: Gifts / Investments / Savings / Etc.
________________________________________________________________________
Total student income: _______________________
Personal references:
1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________
Community Service
On a
separate piece of paper, please outline your personal contributions to your community
in the past five years. Be sure to give
names/ locations of service, dates, hours,
descriptions of service/volunteer duties and name of a contact person. (Examples of community service- boy scouts,
girl guides, 4H, candy striper, other hospital volunteer, service clubs, YMCA,
red cross, senior citizens, church work, recreation, coaching, etc. .
As well,
please provide a commentary explaining why the Rotary Club of Barrie-Huronia should consider your application.
Declaration
I,
________________, hereby apply for a bursary award under the terms of
(name of
applicant)
the
Rotary Club Community Service Award, and I hereby declare that all information
given is complete and accurate and that I will be a full-time student for the academic
period stated, and that the financial aid is essential to enable me to continue
my post-secondary education, and that if I am approved as a recipient, I will
use the proceeds of my award for payment only of educational and living costs
directly related to my course of study.
Signature
of applicant: ____________________ Date:_________________
Submit application
by one of following methods to:
Vocational Services Committee
Director:
Email: ceo@aeronorth.com
Fax:
705-727-9930
Mail : Rotary
Club of Barrie-Huronia
L4M
4T2
All
submissions are confidential to the
selection committee of the Rotary Club of Barrie- Huronia.