2012 Scholarship Application Form - Boys and Girls Clubs of Canada

2012 Scholarship Application FormTo be completed by the applicant.Application Deadline: March 9, 2012 at your ClubNOTE: APPLICANT MUST BE ENROLLED IN FULL-TIME STUDIES AT AN ACCREDITED POST-SECONDARY INSTITUTIONBEGINNING SEPTEMBER 2012 OR THE SCHOLARSHIP WILL BE REASSIGNED.General InformationFirst Name Initial Last Name M FApt. # Street Address City Province Postal CodePhone NumberCellDate of Birth D M YSIN (Mandatory) E-mail Student NumberHave you applied for a Post Secondary Program Y N OR Are you enrolled in a Post Secondary Program? Y NWhat program are you enrolled in/ applying for?Where is the Program offered? (School Name) City ProvinceHave you received a scholarships from BGCC in the past?If yes, pleaseindicate2011 2010 2009 2008 2007**Are you related to a current Boys and Girls Club employee or Board Member ? Y NIf yes, please indicate their name, position and relationship to you:Club Participation InformationWhat Club are you affiliated with? City ProvinceHow many years have you been involved with the Boys & Girls Club?Member* Volunteer StaffWhat Club programs and/ or activities have you been involved with?Other Volunteer/ Community Service OrganizationsNumber of YearsDescription of involvementOther Volunteer/ Community Service OrganizationsNumber of YearsDescription of involvement* Applicant must be a current of former member for a minimum of one year** Relationship means son/daughter, brother/sister, niece/nephew, grandchild, step of half child or any child living under the same premises as an adultwho has legal guardianship.SEE NEXT PAGE

Expenses and IncomeIncome for the School YearPersonal SavingsExpenses for the School YearSchool RelatedTuition and FeesEmployment Income Books and Supplies InstructionsFamily ContributionsScholarships/ Bursaries *Other (Please Specify)Travel (relocation costs**)Living RelatedAccommodation (Rent,phone, cable, utilities, etc.)Transportation (car, bus)Food (school year)OtherPrior Financial Obligations(E.g.. Student Loans)Child CareOther (Please Specify)2012 Scholarship Application FormTo be completed by the applicant.Application Deadline: March 9, 2012 at your ClubAll Income and expenses listedshould be the anticipatedtotal for the school year.Take the total income from Box Aand subtract it from the totalexpenses from Box B to get yourtotal for Box CTotal C:Total A:Total B* Confirmed and Anticipated (do not include this scholarship) Existing Student Loans should be listed as Prior Financial Obligations** Only applicable if you will be attending school out of townLetter of IntentIn 350 words or less, please tell us about your career and educational goals for the future and how a Boysand Girls Clubs of Canada Scholarship will help you meet or overcome barriers to your success.(Please provide this essay on a separate sheet of paper)Legal ReleaseApplicant (or applicants' parents or legal guardian(s) if applicant is under 18 years of age) warrant by their signature thatthey have read and understand the following declaration and release.Applicant Name (18 yrs +)Declare the following:Parent's/ Legal Guardian's Name1. That I have read and understood and comply with the criteria that is related to this application2. That I have honestly and accurately completed all aspects of this application3. That I understand that all submissions including all intellectual property rights, become property of Boys and Girls Clubs of Canada. I understand that Boys andGirls Clubs of Canada reserves the right to use all such material they receive . I consent to the use of my name and/ or photo in any form of media in conjunctionwith Boys and Girls Clubs of Canada Scholarships.4. That I understand that personal information such as my Social Insurance Number (SIN) is required by the Canada Revenue Agency (CRA) for the purpose ofissuing T4A Slips. Personal Information of this nature will not be shared, traded, sold or used in any manner not explicitly approved by you. If you have anyquestions or concerns regarding Boys and Girls Clubs of Canada and your privacy, please visit our web site at: www.bgccan.com or contact our Privacy Officer atprivacyofficer@bgccan.com.5. That should my financial situation change significantly, (i.e. notification of additional scholarships etc.) after the submission of my application, I will notify theBoys and Girls Clubs of Canada for discussion.NameSignature

Letter of RecommendationAt least one to be completed by a Club staff, teacher, coachetc., NOT a family member.Name of ApplicantName of Person Completing FormTitleOrganizationTelephone NumberE-mail AddressRelationship to Applicant (e.g. Teacher, Program Director, etc.)How long have you known the applicant?Why do you recommend this individual as a candidate for a Boys and Girls Clubs of Canada Scholarship (please consider the individual'scontributions to their Boys and Girls Club, years of membership, financial need, community involvement, and personal attributes)? (Pleaserespond to the following in the space provided)

Please Note: This form should be completed in confidence by a Club staff/ volunteer who knows the applicant well and signed by theExecutive Director/ President or other signing officer and placed in a sealed envelope separate from the application form.Applicant NameName of person completing formNominating ClubHow long have you personally known the applicant?Club Nomination Form(If you require more space for the questions below,please provide on a separate sheet)Please indicate this applicants need for financial assistance:Low NeedDoes not requireMedium NeedWould be helpfulHigh NeedCould not attend withoutPlease explain the reasons for your ranking(describe things such as family, home, andemployment situation, other scholarshipopportunities, etc)Please describe the applicant's level ofinvolvement with the Club (considernumber of years, volunteer service, Clubwork, leadership at Club, etc.)In consideration of the two primaryqualifications (financial need and Clubinvolvement), please provide any otherdetails that the selection committee shouldconsider regarding this application (e.g.activities outside the Club, personalattributes, community involvement, etc.)Are you related to the applicantIf yes, please indicate your relationship**Person Completing this form Position DateTelephone NumberE-mail AddressREQUIRED: By selecting this check box, I certify that the information provided above was filled out by me, the Club Staff/ Volunteeror Executive Director (mentioned above) and that all the statements made about the applicant on this form are true to the best of myknowledge. My signature below is a true representation of the validity of the information.Club Staff/Volunteer SignatureExecutive Directors E-mail AddressExecutive Director's Signature** Relationship means son/daughter, brother/sister, niece/nephew, grandchild, step of half child or any child living under the same premises as an adultwho has legal guardianship.

Final Application Check ListCompleted application must include the following:Fully completed application form, with the legal release signedLetter of Intent submitted on separate sheet, maximum 350 words or lessMinimum of One Letter of Recommendation (Not from a family member)A Club Nomination Form in a separate, sealed envelopeA current/ most recent copy of an official transcript

2012 Scholarship Application FormTo be completed by the applicant.Application Deadline: March 9, 2012 at your ClubScholarship DetailsBoys and Girls Clubs of Canada is pleased to offer post-secondary scholarships to eligible youth members fromacross Canada. Scholarships will be provided to deserving youth for the 2012/2013 academic year. Applicantsmust be enrolled in a full-time program at an accredited post-secondary education institution beginningSeptember 2012. Scholarships range in value from $1,000-$4,000.Scholarship recipients will be notified in writing no later than June 4, 2012, and funds will be forwarded to theapplicable post-secondary institution by September 28, 2012.Criteria1. Applicant must be a current or former Boys and Girls Club member for at least a minimum of 1 year.2. Applicant must be a maximum of 24 years of age at the time of application.3. Applicant must be pursuing some form of full time post-secondary education (e.g. College, University or tradesschool), diploma, degree, apprenticeship, or other program, at an accredited post-secondary institution in Canadabeginning September 2012. Program must be one year in length at a minimum.4. Applicant may apply at any point during his or her pursuit of post-secondary education.5. Full time employee's of the Boys and Girls Club are not eligible (seasonal and part-time employees are eligible toapply).Note: Past recipients are invited to apply, however preference may be given to first time applicants.Application ProcessThe following factors will be taken into consideration when selecting scholarship recipients:-Boys and Girls Club membership-Level of participation- Financial Need-Other community or volunteer activities-Letters of Recommendation-Boys and Girls Club ranking (where applicable)-Club Nomination Form-Full Completion of application and supporting documentsSelection Process1. Submit your application with all sections completed and the legal release signed2. Submit a minimum of one Letter of Recommendation with the application. You may send up to two letters ofreference however, at least one must come from someone not related to you.3. Submit a completed Club Nomination Form in a separate, sealed envelope4. Submit an official transcript of the education level most recently completed (photocopies are accepted)5. Submit the completed Application to your Club with all required attachments no later than March 9, 2012.