1. Name: Rotary Club of Peterborough Bursary

Rotary Club of Peterborough P.O. Box 172, ON, K9J 6Y8

2. Purpose: The Rotary Club of Peterborough is committed, through a bursary, to financially assist the first year of post-secondary education for two(2) students (one female and one male if below criteria is met) who are residents of City & County of Peterborough and will be attending the Kawartha Trades & Technology Centre at Fleming College.

3. Bursary: Two bursaries in the amount of $1,000 each will be awarded on an annual basis ($500 for fall semester and $500 for winter semester) paid directly to educational institution.

4. Criteria for Granting the Bursary: The Rotary Club of Peterborough Bursary is to be awarded to a student who:  is a resident of City & County of Peterborough and graduating from City of Peterborough high school  completed a high school credit in a skilled trade’s course  has been accepted into Kawartha Trades & Technology Centre at Fleming College in an accredited trades program and who intends to complete a diploma program.  Is under the age of 25 as at June 30th of the year of application volunteerism; and  would otherwise be restricted financially from pursuing further studies in a post-secondary institution.

5. Criteria for Administering the Bursary:  The Directors of the Rotary Club of Peterborough Bursary shall be the Committee Chair and 2-3 other Rotarians plus 1-2 representative from Peterborough High School’s or School Board for a total of 5.  The contact person for the Rotary Club of Peterborough shall be the Committee Chair.  The Rotary Club of Peterborough will advise the eligible schools in writing by April 30th of each year confirming the number and amount of the bursaries for the coming year. The notification will include the name and phone number of the contact Rotarian.  The completed bursary application form shall be sent by the applicants to the Bursary Committee chairperson or designate by May 31th.  The Bursary Committee shall recommend bursary recipient candidates, together with the reasons for recommendation, to the Rotary Club of Peterborough Board of Directors.  The winner of the bursary will be advised in writing from the Bursary Committee.  The bursary cheque(s) will be presented to the recipient at a Rotary meeting once the School District Secretary- Treasurer receives proof of registration and course payment. The cheque will be made out to the post-secondary education centre. 6. Conditions for Accepting the Bursary:

A student who accepts the bursary shall agree to either prepare an article for publication in the Rotary Club of Peterborough Bulletin or address a regular meeting of the Rotary Club of Peterborough AND provide a Consent form for the Education Institution to advise Rotary of status of enrollment. Rotary Club of Peterborough P.O. Box 172, ON, K9J 6Y8

APPLICATION DEADLINE – May 31, 2015 The Rotary Club of Peterborough Bursary will be awarded to students who would otherwise be restricted financially from pursuing post-secondary education that will lead to a degree program at Kawartha Skills Trades & Technology Centre.

All sections of this application form must be completed as best as they can be and mailed to above address or emailed to Committee Chair – Atul Swarup, [email protected], (705) 931-5111.

Personal Data: Name: Given: ______Last: ______Address: ______Postal Code: _____ - ______Mailing Address (if different): ______Phone: ______-______-______Email: ______Social Insurance Number: ______-______-______Citizenship: Canadian Yes - No. Other:______Married: Yes/No . Children: Yes/No . Ages: ______I have been attending school in Peterborough for ______years. I have been living in Peterborough/County for ______years. High School: ______. Date of Graduation: ______Curriculum: ______or Present Occupation: ______I have (acceptance) or (have applied to) the following institutions preferred by me: a) ______Course of Study: ______b) ______Course of Study: ______c) ______Course of Study: ______

Do you have a student ID# from the institution: Yes/No. The ID# is ______.

Participation in school and community activities Leadership:

Citizenship:

Volunteerism: Rotary Club of Peterborough P.O. Box 172, ON, K9J 6Y8

Fill in this Budget based on the Study Period for this Application ( Ex. A ‘study period’ may vary. University/College is typically September to April. Bursaries provided are for one ‘study period’. )

Income for Study Period Type Amount Total of all savings and investments at the beginning of your Study Period before paying for any educational costs Academic Awards, Scholarships, Bursaries. Specify Type or Source:______

OSAP funding granted for the following amount: Estimate is acceptable Application for OSAP has been made: (Yes) (No) (I am applying.) Students Net Income from Part Time work during Study Period Registered Educational Saving Plan available to Student for Study Period Child Tax Credit, ______per month X ______months Parents or Guardian Contributions for your Study Period Child Support Payments payable to you ______/mo. X ____months Rental Income, Alimony, or Sale of Assets.

‘Total Income’ before Other Resources

Expenses Anticipated for Study Period Tuition and Compulsory Fees Accommodation $______/mo X _____ Books and Supplies Food: $______/mo X _____ months Utilities $______/mo X _____ months Phone and Internet $ ______/mo X _____ months Bus Pass, Tickets $ ______/mo X _____ months Clothing $ ______/mo X _____ months

‘Total Expenses’ for Study Period

Total Income’ minus ‘Total Expenses’ Rotary Club of Peterborough P.O. Box 172, ON, K9J 6Y8

Family Information:

Name of Parents: ______Contact at: ______Contact at: ______May we contact your Parents? Yes/No. Address of Parents: ______Combined Income of Parents before taxes: $______Income of parent(s) as shown on Line 150 of their Income Tax Return: ______and ______. Do your parents own their home: Yes/No How many brothers and sisters in your family, excluding yourself? ______How many are in school. ______. Are siblings at or planning a post-secondary institution? Yes/No.

Extra-Curricular Activities: Describe any interests, sports, achievements or recognitions you have had. ______Briefly explain why you should be considered for this bursary (including financial need): ______Questions? Complete the application the best you can. Attach questions or concerns separately.

Consent: The applicant consents to the indirect collection, use, sharing and disclosure of information herein, for the purpose of verifying the information supplied and information not supplied, as it may pertain to this application for funding. The applicant may withdraw this consent at any time by written notice to the address in the letterhead attached. (All information will be kept confidential) The applicant states: I have given true and accurate information in regard to this application. I realize I am responsible for providing any supporting documentation as may be required. If any information is found, at any time, to be untrue, the Bursary provided will be required to be refunded in full.

Signed by Applicant: ______Dated: ______

The Parent or Guardian states the information in regard to their finances is True and Complete.

Signed by Parent: ______Name: ______Dated: ______

Signed by Parent: ______Name: ______Dated: ______Rotary Club of Peterborough P.O. Box 172, ON, K9J 6Y8

School Principal/Teacher/Counsellor Reference:

Briefly explain why this student should be considered for this bursary (including financial need): ______

I certify that the information contained in this application is true & accurate to the best of my knowledge.

Signed by Teacher/Counsellor: ______Dated: ______

Signed by Principal: ______Dated: ______