OFFICIAL USE ONLY
Application #  	 Division  	
Date Rec’d  	

Kansas Kiwanis Foundation, Inc.
2020-2021
High School Senior Scholarship Application
(KKF Form 100)

THIS APPLICATION FORM TO BE USED BY HIGH SCHOOL STUDENTS ONLY!
COLLEGE STUDENTS USE KKF COLLEGE SCHOLARSHIP APPLICATION FORM 101

The Kansas Kiwanis Foundation is proud to offer scholarships to deserving students who are graduates of Accredited Kansas High Schools. Should special circumstances exist they will be evaluated on a case-by-case basis to determine eligibility.

Fill out this application completely. Failure to do so shall result in your application being disqualified! You may go to the Kiwanis Web Site at www.kskiwanis.org then click on the Kansas Kiwanis Foundation on the right side.
1.	Previous editions of this form are obsolete. Use of any other application format shall result in your application being disqualified.
2.	You do not have to be a member of a Key Club to apply.
3.	Mail application and required letter of recommendation to Secretary, Kansas Kiwanis Foundation, P.O. Box 3628, Olathe, KS 66063
4.	Application MUST be postmarked not later than April 20, 2021 for your application to be considered.

SECTION I. Personal Information:
a.	Name:  	

b.	Address:  	

City: 	_ State: 	Zip: 	Email 	

Telephone:  	

SECTION II. Key Club: (complete only if a Key Club member)
a.   Member of the 	Key Club.  Number of years  	
b.   Office(s) Held/Year:	(1) 	/ 	(2) 	/ 	(3) 	/ 	(4) 	/ 	
c.	I certify that the above named applicant is a member in good standing of Key Club of  	
d.	Signed:  	
Key Club Faculty Advisor, District Key Club Administrator or Local Kiwanis Club Secretary (Circle one)
SECTION III. Parent or Legal Guardian Information:

a.	Name 	Relationship to applicant: Father_    Mother 	Guardian 	
b.	Address:  	
City: 	State: 	Zip: 		Telephone:  	
c.	Occupation: Father 	Mother 	Guardian  	
d.	Signature of Parent or Guardian:  	

SECTION IV. Kiwanis Club Membership:

a.   Do you have a family member in Kiwanis (if so) what club?  	
b.   Office(s) Held/Year (1) 	/ 	_ (2) 	/ 	_ (3) 	/ 	_ (4) 	/ 	

SECTION V. Scholarship To Be Used At The Following Institution:
a.	Name of Institution:  	
b.	Address:  	
a.	
SECTION VI. Educational History
Student: Fill out the information before taking it to your school counselor. Take an envelope with your name on the outside for him/her to seal this page in once it is completed.

Student Name  	

Name of School from which you will receive your diploma:  	

Years attended: From: 	to: 		School Address  	
Name of School Counselor:  	
SECTION VII. Evaluation by School Official
Counselor: please complete the following evaluation of this student. Do Not attach a letter of recommendation. Please seal this page and an official transcript into an envelope if returning to the student to mail. If your school office mails completed scholarship applications for students there is no need for the added envelope.

GPA: 	based on a 	scale.		Class Ranking: 	of	 ACT/SAT Composite Score  		
Did this student complete the Kansas Regents Qualified Admissions Curriculum?	Yes [	] No [ ]
A school official must complete the following for this application to be considered. This student is applying for a scholarship, and we use the information in selecting recipients. Due to Federal Legislation the student may request and be given permission to see your recommendation.
Please evaluate the applicant’s personal qualities

PERSONAL
QUALITIES	Truly
Outstanding	Excellent	Good	Average	Below
Average	No Basis for
Judgment	Comments	
Motivation								
Leadership								
Dependability /
Responsibility								
Cooperation								
Intellectual Curiosity								
Ability to work
independently								
Initiative								
Self-Discipline								
Integrity / Honesty								
Resilience								
Maturity								
Emotional Stability								
Social Adjustment								
Concern for Others								
Please mark the basis for your ratings. You may mark as many as apply.
 	Records and Reports	 	Personal acquaintance	 	Casual Contacts	 	Counseling contacts
 	Committee Evaluation	 	Other	 Has/does this student:
Had disciplinary problems in school?  Yes [   ] No [		]	have any special health or physical problems? Yes [	] No [	] Had disciplinary problems in the community Yes [	] No [		]	have any learning disabilities Yes [	] No [	]
Do you recommend this student for admission to an institution of higher education? Yes [	]  No [	] Any comment you would like to make on behalf of this student:

Signature and Title 	_ Date  	

SECTION VIII. Activities: confine lists to the space provided
a.	Activities while in High School: Use the following format when listing activities:
Activity (Explanation of activity if not well known or obvious), Duration (Years, Weeks, Days of activities)	
Example:
Student Council, FFA Representative 1 year, V.P. 1 year, Pres. 1 year	Meetings one hour long, every other week
during school.	

		

		
		
b.	High School Awards and Honors: Use the following format when listing activities:
Award / Honor (explanation of award if not well known or obvious, year(s) received, source of award
Example:
Prudential Spirit of Community Award	
Junior year	
Prudential Insurance Company	

			
			
SECTION IX. Community Service Performed while in High School only. Use this format when listing Service:
Specific service or service project, duration (years, months, weeks), total number of service hours involved, origination of the projects (Club, Church, class or individual) Do not group projects.
Service which does not qualify to be included: Paid or stipend service, any form of fundraising, lobbying, efforts directed to serve only a family member and serving as an officer of an organization.
Example:
Volunteer in pediatrics ward of St. Francis Hospital	
3 years	
297 hrs total	
Self initiated	

				

				

				

SECTION X. Expectations: Answer all questions in the space provided; be specific.
a.	If you could only give one piece of advice to someone younger than yourself about how they can achieve their life goals, what would that advice be? Expound about it.

b.	Where do you expect to be in 15 years? What obstacles (disregarding finances) do you expect in getting there?

SECTION XI.  Financial:  What is the yearly cost of attending your chosen school? $ 	

How do you plan to finance your education?

List summer and academic-year jobs you have held since entering high school.

List ALL members of your family living at home, or currently enrolled in college (including yourself) and their ages:

Father Mother Yourself
SECTION XII. Transcript
Ask your counselor to furnish an official copy of your high school transcript for this application. He/She may include it in the envelope with page 2, or they may simply attach it if their office mails scholarship applications for students.
SECTION XIII. Applicant’s Statement
In submitting this application I certify that:
a.	I will be a full-time student at the educational institution I attend;
b.	I will use the proceeds of this scholarship for the payment of tuition, required fees, room, board and or required material/books.
c.	I agree to release my grades to the Kansas Kiwanis Foundation and I will request a copy of my official transcript(s) be mailed with this application;
d.	I will attach one (1) Letter of Recommendation (page 5) from a community or religious leader or neighbor (other than a person affiliated with your school) and,
e.	That the information submitted with this application is, to the best of my knowledge, true and correct.

SIGNED: 	Date: 	/ 	/ 20 	

Letter of Recommendation
Give this sheet to a community, religious leader or neighbor (other than a person affiliated with your school)

Name of your reference letter author_____________________________________

How have you been involved with them___________________________________

Attention: Writer of Letter of Recommendation. We will have a copy of the student’s transcript. He/She will list high school activities, awards, honors, and service performed. What we would like from you are comments on the student as a person, the person as a student, how you know the applicant, how long you have had a relationship, and how much you have observed the applicant delivering service to target populations. Please include in what role you are familiar with the student. You may use this page for your letter, or use a letterhead instead.

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