GLASGOW NOON ROTARY CLUB
DR. JUANITA C. BAYLESS SCHOLARSHIP
"HE PROFITS MOST WHO SERVES BEST"
(Attach recent photo
here for publicity
purposes. approx
2" x 2")
WKU-GLASGOW or KCTCS SCHOLARSHIP ($500)
(Student must be enrolled or planning to attend the Glasgow Campus of Western Kentucky
University or KCTCS)
DEADLINE IS APRIL 15TH ! (Please return to counselor)
I.. PERSONAL INFORMATION
NAME__________________________________________________SS#__________________
CHECK ONE: _____ HIGH SCHOOL SENIOR OR GRADUATE OF: ___________________
_____ CURRENTLY ENROLLED AT _________________________________
WITH _______ HOURS COMPLETED THUS FAR.
_____ OTHER ____________________________________________________
SEX ________DATE OF BIRTH__________ MARITAL STATUS_______________________
HOME ADDRESS______________________________________________________________
____________________________________________________PHONE___________________
FATHER______________________________ OCCUPATION__________________________
MOTHER_____________________________ OCCUPATION__________________________
SIBLINGS (Give name, sex, age, and occupation) _____________________________________
______________________________________________________________________________
______________________________________________________________________________
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II. COLLEGE PLANS
1. IN WHAT FIELD DO YOU PLAN TO MAJOR? __________________________________
2. IF UNDECIDED, LIST YOUR PREFERENCES. A. ________________________________
B.________________________ C. ______________________________________________
3. IF YOU HAVE SELECTED AN OCCUPATION OR PROFESSION, LIST IT HERE.
______________________________________________________________________________
III. HIGH SCHOOL EDUCATIONAL INFORMATION
1. FROM WHAT HIGH SCHOOL DID YOU/WILL YOU GRADUATE?
______________________________________________________________________________
2. LIST YOUR MOST SIGNIFICANT HONORS, AWARDS, AND EXTRA-CURRICULAR
ACTIVITIES. _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
IV. DETAILED BUDGET INFORMATION
INSTRUCTIONS: Please give a detailed budget for the school year when you will use the
scholarship. Show amount, sources of funds you expect to get, as well as your work experiences
in your lifetime, including what money you have made during the past 12 months and how. Also,
are you working now and do you plan to do so in the year these funds will be used? (attach extra
sheets if necessary)
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ATTACH A PAGE WITH COMMENTS WHICH YOU WOULD LIKE TO MAKE THAT
MAY HAVE A BEARING ON THE DECISION OF THE SCHOLARSHIP AWARDS
COMMITTEE. INCLUDE WHY YOU SELECTED THE COLLEGE OR UNIVERSITY YOU
WISH TO ATTEND WHILE USING THIS SCHOLARSHIP, AND OTHER FACTORS THAT
DEMONSTRATE MERIT AND/OR NEED.
TO BE FILLED OUT BY THE APPROPRIATE SCHOOL OFFICIAL AFTER APPLICANT
HAS COMPLETED THE PREVIOUS SECTIONS
1. PLEASE INCLUDE TRANSCRIPT TO INCLUDE CURRENT SEMESTER
2. NUMBER IN APPLICANTS GRADUATING CLASS___________.
APPLICANT'S RANK (IF KNOWN)___________.
3. GRADE POINT AVERAGE __________ SCALE USED _______________.
4. AMERICAN COLLEGE TEST RESULTS (Please report in standard scores.)
ENGLISH __________ MATH __________ READING __________
SCIENCE REASONING __________ COMPOSITE __________
5. SAT.: VERBAL __________ MATH __________
6. RECOMMENDATIONS OR REMARKS FOR THE SCHOLARSHIP AWARDS
COMMITTEE. _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DATE _______________
SIGNED _____________________________________
PRINTED NAME _____________________________
TITLE ______________________________________
7. PLEASE LIST THE SCHOOL OFFICIAL(S) TO BE NOTIFIED IF THE SCHOLARSHIP
IS AWARDED.
______________________________________________________________________________
CONSENT FOR RELEASE OF STUDENT INFORMATION
I hereby give my permission to the Scholarship Awards Committee to publicly announce my
special achievement. If such recognition involves reviewing my gradepoint average and scholastic
record, this committee has my permission to use such information. I also authorize the committee
to share my application with any interested community club or organization for the purpose of
awarding scholarships.
_______________________
(Social Security Number)
____________________________________
(Student’s Signature)
________________________
(Date)
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(Parent’s Signature)