MISSION STATEMENT:

Building a better future for our children

Kiwanis Cal-Nev-Ha Foundation

Scholarship Application Instruction Page

Cali-Nev-Ha Key Club & Cal-Nev-Ha KIWIN’S Key Club

Received by Deadline: FEBRUARY 21, 2013

Note: Applications received after this date will NOT be considered by the judging committee.

Mail to: Kiwanis District Office, Attn. Service Leadership Programs Scholarships

8360 Red Oak St., Suite 201, Rancho Cucamonga, CA 91730-0608

Please clearly separate scholarship applications from convention registration and contest entries.

This application will also be used as the initial application for the Loretta Barksdale McElwain scholarship with a

value of approximately $20,000.00. Applicants will be requested to submit separately the Free Application for

Student Aid (FAFSA) Student Aid Report to be considered for this award.

Instructions: Please read all instructions before beginning the application process!

1. FOLLOW DIRECTIONS!!!

2. The application is divided into three sections but weighed differently

a. Service as a Kiwanis Member (CNH/KIWIN’S Key Club only)—60% of your score

b. Service to your School (other than CNH/KIWIN’S Key Club)—20% of your score

c. Service to your Community (other than CNH/KIWIN’S Key Club)—20% of your score

NOTE: Duplication of activities in more than one section will not be considered by the judges.

Specifically comment on your contribution to the project. Statements like “10/2006 Organized PTP car

wash; 20 members; raised $5000” carries more weight with the judges than, “Car Wash 10/2006”

3. Applicant must be a high school senior who plans to enroll full time in a college, university, or institution of

higher education the next year.

4. Applicant’s name must appear on both District and International dues forms from the current year.

5. Complete the application.

a. Limited to this pdf-fillable form only (Acrobat Reader is needed): Any modification or change to this

form will not be considered by the judges.

1) You are limited to the number of slots provided.

b. Entire application (except for signature lines) must be typed. ADOBE READER USERS: Form must be

printed without saving.

c. Times or Times Roman font only (Form default)

d. Font size must be 9-point or higher (Form default)

e. No attachments!

6. Tips: Use dates. Record specific accomplishments, number of people served, awards received and recognition

given. Provide sufficient information so the judges understand the nature of the project and your

involvement in the project.

www.cnhfoundation.org

8360 Red Oak Street, Suite 201 Rancho Cucamonga, CA 91730-0608

Office: 909-989-1500 Fax: 909-989-7779 Email: foundation@cnhkiwanis.org

Kiwanis C a l -N e v - H a F o u nd a t i o n

Kiwanis Cal-Nev-Ha Foundation

Scholarship Application Cover Page

Cali-Nev-Ha Key Club & Cal-Nev-Ha KIWIN’S Key Club

Received by Deadline: FEBRUARY 21, 2013

I am applying for the following CNH scholarship.

CNH Key Club or KIWIN’S Key Club Note: Applications received without a category designation will NOT be considered by the judging committee.

Applicant Name

Last Name First Name Middle Initial

PERSONAL INFORMATION

Address

Street City State Zip

Home Phone Cell Phone Social Security #

E-mail

KIWANIS FAMILY INFORMATION

# of years in CNH/KIWIN’S Key Club? Previous K-Kids Member? (Y/N) Years

Parent(s) members of Kiwanis? (Y/N) Previous Builders Club Member? (Y/N) Years

MEMBERSHIP INFORMATION

(Obtain from club secretary or Key Club International)

Member Identification # Region Division

Club Club Identification #

Sponsoring Kiwanis Club

ACADEMICS

Applicant is a high school senior who plans to enroll full time in a college, university, or institution of

higher education next year. (Y/N)

Applicant’s FAFSA Student Aid Report will be available if requested? (Y/N)

Academic (weighted) G.P.A. This school does not weigh grades. (check if appropriate)

Verified by: Name Signature (select one) Faculty advisor Counselor School Registrar

EMPLOYMENT

Did you hold a job during high school? Average # of hours worked each week?

Where?

I verify that all information contained herein is correct

Typed Name of Applicant Signature of Applicant Date

MISSION STATEMENT:

Building a better future for our children

www.cnhfoundation.org

8360 Red Oak Street, Suite 201 Rancho Cucamonga, CA 91730-0608

Office: 909-989-1500 Fax: 909-989-7779 Email: foundation@cnhkiwanis.org

Kiwanis C a l -N e v - H a F o u nd a t i o n

THIS LINE IS FOR CNH KIWANIS FOUNDATION USE ONLY Applicant #

NOTE: Duplication of activities in more than one section will not be considered by the judges. Check the criterion

for each category before completing each section.

(Obtain from club secretary or district dues report)

Current club membership? What year was this club chartered?

# of years in CNH/KIWIN’S Key Club? Total # of CNH/KIWIN’S Key Club service hours?

CNH/KIWIN’S KEY CLUB SERVICE 60% of your score Indicate service completed as a CNH/KIWIN’S Key Club member, projects chaired, service

projects organized, events attended, offices held, etc.

Indicate only the top twenty (20) service projects that you completed as a CNH/KIWIN’S Key Club member.

Example:

Name of the project or event Date (list multiple

dates together) Describe your role and/or contribution to the project or event

Alumni Luau Service Project 6-07 Recruited 40+ members to volunteer; coordinated on site assignments

Junior High School Mentor Program 11th- 12th grade Mentored two 7th grade students in math & science

Your service:

KEY CLUB Kiwanis Cal-Nev-Ha Foundation Scholarship Application Page 3 of 4

NOTE: Duplication of activities in more than one section will not be considered by the judges. Check the criterion

for each category before completing each section.

Indicate only the top fifteen (15) Kiwanis Family events that you attended as a CNH /KIWIN’S Key Club

member.

Example:

Name of the project or event Date (list multiple

dates together) Describe your role and/or contribution to the project or event

Key Club International Convention 2010/ 2011/ 2012 Attended Tour & ICON; delegate each time; Social Media Team volunteer

Kiwanis Club of Endor Senior Year Two per month; gave club report to Kiwanis & Kiwanis report to club

Your activities:

Indicate up to your top ten (10) offices or positions held and up to your top ten (10) honors received as a

CNH/KIWIN’S Key Club member. Indicate whether office positions are elected or appointed positions.

Example: Leadership Positions Held Example: Recognition or Honors Received

Name of the office or position

When did

you serve?

Elected or

Appointed?

Name of the recognition

Date (list

multiple dates

together) Division 100 Lt. Governor 2006-2007 Elected Member of the Month 4/2004, 10/2007

PTP Car Wash Project Chair 2005-2006 Appointed Top Fundraiser: UNICEF 10-2006

Your leadership positions: Your awards and recognitions:

KEY CLUB Kiwanis Cal-Nev-Ha Foundation Scholarship Application Page 4 of 4

NOTE: Duplication of activities in more than one section will not be considered by the judges. Check the criterion

for each category before completing each section.

SERVICE TO THE SCHOOL 20% of your score Indicate offices held (other than CNH/KIWIN’S Key Club) and participation in other

organizations and projects.

Indicate up to your top ten (10) offices held and participation in school organizations and projects not

affiliated with CNH/KIWIN’S Key Club.

Example:

Name of the project or event Date (list multiple

dates together) Describe your role and/or contribution to the project or event

Yearbook 11th grade Sports Editor

Orchestra 9th-12th grade Violin, 3rd chair; Viola, 1st chair

Your activities:

SERVICE TO THE COMMUNITY 20% of your score Indicate organizations and projects you were involved in through your religious institution,

other community service groups not affiliated with Kiwanis or your school, and any activities accomplished on

your own.

Indicate up to your top five (5) community service activities not affiliated with Kiwanis or your school.

Example:

Name of the project or event Date (list multiple

dates together) Describe your role and/or contribution to the project or event

Sunday School 2007 Taught 2nd grade classes each week

Camp Sunshine 8 weeks, 2007 YMCA summer camp counselor; Crafts Instructor

Your activities: