The Scholarship award will be no more than $2,500 per year, renewable annually three times over a total span
of no more than five consecutive years and for a maximum total award of no more than $10,000.

Major factors considered areName:

• Financial Need   
• School Achievement & Scholastic Potential  
• Personal Qualities    
  • (participation in extra-curricular activities, work experience, volunteer work, hobbies, etc.)

STUDENT'S NAME ___________________________________________________________________

Address: ______________________________________________________________________________

Telephone: ________________________

FATHER'S NAME & ADDRESS ________________________________________________________

____________________________________________________________________________________

Where employed and position _______________________________________________________________

MOTHER'S NAME & ADDRESS _______________________________________________________

____________________________________________________________________________________

Where employed and position _______________________________________________________________

Name and age of sibling and/or others dependent on your family for support: _____________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Choice of school and why?______________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Major field of study ___________________________________________________________________

Extra-curricular activities (school, community, church, work) __________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Summer plans ___________________________________________________________________________________

What will be the total freshman financial requirement at the school of choice?

1st choice school - $_____________________

2nd choice school - $ ____________________

Money available to student to meet first year college needs

            Student's Savings  $ ____________

            Student's Earnings - Summer job $ ____________

            Work / Study at college  $ ____________  

            Scholarships and grants ( list name and amount)  _____________________________     $____________

          _____________________________________________________________________    $_______________

          _____________________________________________________________________     $____________    

            Amount  to be contributed by parents ( as determined by FAF, BEOG, SEOG applications ) $__________

            If you are the beneficiary of an educational trust, how much will that contribute?           $_____________

            Other sources   1_________________________________________________            $_____________

                                     2_________________________________________________            $_____________

Total      $____________

Will you be willing to borrow to further your education? ____________________________________________

For what scholarships did you apply?

       Source 1 ______________________________________  Amount $_____________  Granted   $____________

       Source 2 ______________________________________________  Amount $_____________  Granted   $____________

       Source 3 ______________________________________  Amount $_____________  Granted   $____________

Will obtaining additional financial aid be a prerequisite to continuing your education?  

_____________________________________________________________________________________________

Name and phone number of 2 individuals (one associated with the school and one not associated with
school) who would be willing to speak to the committee regarding your character and qualifications.

Name 1:_______________________________________     Name 2: ________________________________________

Telephone 1:_________________________                          Telephone 2. _________________________

Why do you feel you should be granted a scholarship? (Answer in detail.)
You may attach a separate sheet to answer more fully than space allows.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Student's Signature _____________________________________________

Parent's Signature ______________________________________________

All applications submitted become the property of the Essex Rotary Club, and shall be kept confidential.

Mail to:
Essex Rotary Club Scholarship Foundation
P.O. Box 484
Essex, Connecticut 06426

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