P. O. BOX 186 DEERFIELD, IL 60015
www.deerfieldoptimist.org
Name: ______________________________ Phone: (_____) _____________________
Address: _______________________________________________________________
City: _________________________________, IL Zip: __________________
E-Mail: _____________________________
High School: ___________________________ Graduation Date: __________________
School Phone: _________________
Service to the Community is defined as “voluntary, uncompensated effort benefiting
a non-profit organization or individuals.”
SECTION A: VOLUNTEER / COMMUNITY SERVICE ACTIVITY SUMMARY
Activity (Type of Service) Organization Dates of Service
1. ____________________ _______________________ __________________
2. ____________________ _______________________ __________________
3. ____________________ _______________________ __________________
4. ____________________ ________________________ __________________
5. ____________________ _______________________ __________________
6. ____________________ _______________________ __________________
7. ____________________ _______________________ __________________
(If necessary, additional space may be used to complete section A)
SECTION B: volunteer / community service EXPERIENCES
On additional paper, please write about no more than four of your volunteer activities that you feel had the greatest impact on others. Please do not write more than one page about any one activity and include the following information.
· The purpose of the activity.
· Your role in the activity.
· The amount of time contributed per week, month, or year.
· The number of people served by this activity.
· Describe the impact of your involvement on those you served and on yourself.
· If you held a position of leadership, describe the impact of your leadership on the activity.
· Provide the name, email address and telephone number of the adult sponsor or supervisor who can verify your participation.
SECTION C: SPONSOR RECOMMENDATION
You must submit a letter of recommendation from the organization(s) you chose to include in Section B. The letter(s) of recommendation must be in an original sealed envelope with the adult sponsor’s signature across the seal. They may be sent directly to the Optimist Club or they may be included in your application package. Please note that if sent directly, the letters must be postmarked no later than April 7th, 2008.
Permission is given for the OPTIMIST CLUB OF DEERFIELD to contact any organization and / or individual listed in my application for the purpose of verifying information or statements I have made in this application. If selected for an award, the Optimist Club of Deerfield has permission to use a picture that I furnish to publicize the awards.
By: _____________________________________ Dated: __________________
Applicant’s signature required
Please return this application, along with all required information to:
John Coughenour Scholarship Committee
Optimist Club of Deerfield
P.O. Box 186
Deerfield, IL 60015