Kiwanis Club of Madison West Scholarship Program
Kiwanis Club of Madison West Scholarship Program Ernie Rothe Annual Memorial Leadership Scholarship Application Student’s Name: ________________________________________________________ Last First Middle
Home Address: _________________________________________________________ Street City State Zip Code
Student’s Home Phone: ( )__________ Student’s Cell Phone: ( )___________ Student’s Edgewood Email: __________________________________ Edgewood Circle K Member Since (list year joined)__________ Grade Point Average on a 4.0 scale ______ Major/Minor field(s) of study ___________________________________________ Father’s Name______________________ Occupation _______________________ Mother’s Name ____________________ Occupation _______________________ Applicant Signature _____________________________ Date _________________ Parent Signature ________________________________ Date_________________ (Father and/or Mother)
Send or email- (email preferred) entries no later than March 15, 2018 Ken Saville, Program Leadership Chair 4106 Melody Ln Madison, WI 53704 Email: [email protected] Any questions can be addressed to Ken by email.
Application Form- please print or type Name of Applicant___________________________________________Age___________ Home Address_____________________________________________________________ College or School address_______________________________________________
1. Involvement in community and extracurricular activities. List participation in all clubs, programs, projects and activities such as sports, drama, scouting, etc (describe in the space provide)
2. Leadership responsibilities- list offices you have held, committee chairs assigned. Provide a list of honors, awards, and special recognition received in the past four yearsboth in and out of school. Specifically list any Key Club or Circle K offices/positions you have held (Describe in the space provided):
3. Essay on the importance of community service (describe in the space remaining)
Home Address: _________________________________________________________ Street City State Zip Code
Student’s Home Phone: ( )__________ Student’s Cell Phone: ( )___________ Student’s Edgewood Email: __________________________________ Edgewood Circle K Member Since (list year joined)__________ Grade Point Average on a 4.0 scale ______ Major/Minor field(s) of study ___________________________________________ Father’s Name______________________ Occupation _______________________ Mother’s Name ____________________ Occupation _______________________ Applicant Signature _____________________________ Date _________________ Parent Signature ________________________________ Date_________________ (Father and/or Mother)
Send or email- (email preferred) entries no later than March 15, 2018 Ken Saville, Program Leadership Chair 4106 Melody Ln Madison, WI 53704 Email: [email protected] Any questions can be addressed to Ken by email.
Application Form- please print or type Name of Applicant___________________________________________Age___________ Home Address_____________________________________________________________ College or School address_______________________________________________
1. Involvement in community and extracurricular activities. List participation in all clubs, programs, projects and activities such as sports, drama, scouting, etc (describe in the space provide)
2. Leadership responsibilities- list offices you have held, committee chairs assigned. Provide a list of honors, awards, and special recognition received in the past four yearsboth in and out of school. Specifically list any Key Club or Circle K offices/positions you have held (Describe in the space provided):
3. Essay on the importance of community service (describe in the space remaining)
