Bursary and Scholarship Application

Name:*

First NameLast Name
Current High School:*
Physical Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code
Mailing Address (if different from Physical Address):

Address (P.O. Box)

Address Line 2

CityProvince

Postal Code
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Post Secondary Institution Name:*
Course Major:*
Have you been pre-accepted?*

YesNo
Have you accepted an offer to play or participate in soccer, volleyball, baseball, track and field or swimming at the Post-Secondary Institution?*

YesNo
If yes, please upload the applicable documentation.

Cancelof
Please upload a transcript of your marks:

Cancelof

List all of the courses you are currently enrolled in for the 2nd Semester:*

	Course Name	First Report Mark
1
2
3
4
5

Please tell us what your plans are for your post-secondary education and a career (include the faculty or program and the number of years where applicable):*

Community/School Volunteerism

* Required if you're applying for:
1. Brokenhead River Community Foundation Bursary
2. Brokenhead River Community Foundation Scholarship
3. Brokenhead-Thalberg North-Mars-Brokenhead East Scholarship
4. Clinton Orr & Jodi Ruta Community Builder Scholarship
Community Involvement/Volunteer Experience

Please choose and describe the top five ways in which you have volunteered in your community or school sanctioned activities while in grades nine to twelve that have had the greatest impact. If you held a leadership position during these grades, please choose that option and in the space provided indicate the position held. Please chooose the length of time for your volunteerism.

Examples are as follows:

Volunteerism Community Example: Taking part in Cadets Food Drive
- one time would be "1 day or less"
- several days in 1 week would be "multi-day"
- several days over 6 months would be "short-term less than 1 year"
- several days over 2 years would be "long-term more than 1 year"
Volunteerism School Example: Timekeeping for Barons Hockey Team or tutoring other students unpaid.
- Same options as above
- Grad committee in not considered "Volunteerism in School"
Leadership Volunteerism Example: holding a position on Student Council, organizing or leading a school or community volunteer event.
- Same options as above
- Choose yes or no for each one

	Description (include whether School or Community based)	1 Day or Less	Multi-Day	Short Term (less than 1 year)	Long Term (more than 1 year)	Leadership Role (Yes or No) Explain further below
Event 1
Event 2
Event 3
Event 4
Event 5

Please provide additional explanation for your volunteerism above (if applicable)
Participation in Sport

* Required if you're applying for:
1. Madden-Bodnarchuk Sports Bursary
Please identify the sporting activities you took part in while in grades nine to twelve, whether organized through the school or community. If you held a leadership position during these grades, please choose that option and in the space provided indicate the position held. Please choose the length of time for your sporting acitivities.

Examples are as follows:

Leadership in Sport Example: Volleyball Team Captain or Volunteer Coach for Rec Hockey:
- one day would be "1 day or less"
- several days over a weekend would be "multi-day"
- several days over 6 months would be "short-term less than 1 year"
- several days over 2 years would be "long-term more than 1 year"

	Name of Sport	1 Day	Multi-Day	Short Term (less than 1 year)	Long Term (more than 1 year)	Leadership Role (Yes or No) Explain further below
Event 1
Event 2
Event 3
Event 4
Event 5

Please provide additional explanation for your sport involvement above (if applicable)
Participation in Curling

* Required if you're applying for:
1. Beausejour Curling Club Scholarship
2. Robert Rondeau Memorial Curling Scholarship

Fill in applicable curling experience from grades nine to twelve:

	Number of Years	Accomplishments
School Team Member
Curling Club Member
Entered Curling MB Events
Provincial Team Member

Please provide additional explanation for your curling involvement above (if applicable)
Attach a letter from your coach or curling club attesting to your involvement and good sportsmanship

Cancelof
Financial Need

* Required for Bursary Applicants only:
1. Brokenhead River Community Foundation Bursary
2. Eric Lefko Memorial Bursary
3. Ernie Tirschmann Memorial Bursary
4. Gerald & Dr. Pamela Hawranik Bursary for Nursing
5. Madden-Bodnarchuk Sports Bursary
In order to appreciate your individual circumstances, requirements and needs, please select any of the self identification options that apply to your current situation.

I currently live in a rental homeI have other family members who are also pursuing post-secondary educationI have personal or family medical expensesI am supported by only one parent's incomeI am currently working to help pay for my educationI have other personal or family financial challengesI will have to continue to work while I am going to post-secondary schoolI have applied for other scholarships/bursaries outside of the Brokenhead River Community FoundationI have or will have to apply for a student loan to help cover my costs
In the space provided below, please provide any additional information such as specific living expenses you will have while attending post-secondary school (example: estimated tuition fees, accommodation or rent payments, commuting costs if greater than 50 km or other travel costs). Also please identify any life circumstances you would like to share that have impacted you or your family in a negative way that may contribute to your overall financial need.

Declaration of Applicant:

I understand the terms and conditions and hereby make application for a Brokenhead River Community Foundation Bursary and/or Scholarship.

I hereby certify that the information given in this application is true and complete; that the Brokenhead River Community Foundation is authorized to verify the information contained herein with my educational institutions and other sources identified; and that I will notify the Foundation of any changes.

I understand that personal information is collected about me for the purpose of administering the Brokenhead River Community Foundation Bursary and Scholarship program and I agree to allow my name, picture, city/town of residence, institution of study, and future study plans to appear publicly if I receive a bursary or scholarship.
Application must be submitted online by May 31st.

A transcript of your marks must accompany this application if you have applied for a scholarship. Please ensure you have also included any letters of reference or applicable documents at the time of submission.

Please note: the Bursary and Scholarship winners will be acknowledged prior to graduation at the Brokenhead River Community Foundation reception on Thursday, June 19th at 7:00 pm at the Beausejour Sportsplex. If you are awarded a bursary or scholarship, you will be notified in advance and you and your family will be invited to attend. Please keep this date open.
Signature of Applicant:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Brokenhead River Community Foundation

Eligibility

Application