Florence and Cor Van Dam Memorial Scholarship Application

Florence and Cor Van Dam Memorial Scholarship Application

Due May 3, 2026
The Rotary Club of La Mirada is seeking scholarship applications from La Mirada students graduating from high school. The scholarships vary in amount, and are intended to provide financial assistance to students planning to attend a university, college, community college or trade school.
Applicants are responsible for gathering and submitting all required information in the format requested. Incomplete applications and those not conforming to the required format will be disqualified. Information received is considered confidential and is reviewed only by the Rotary Club of La Mirada Scholarship Committee and/or the La Mirada Community Foundation Scholarship Committee.
La Mirada High School scholarship recipients will be notified at the La Mirada High School Awards Assembly; other recipients will be notified by phone or email. Not all applicants to the program will be selected as recipients.
Preference may be given to applicants planning studies that lead to sustainable, high-impact outcomes in one of Rotary's six major areas of focus: peace and conflict resolution, disease prevention and treatment, water and sanitation, maternal and child health, basic education and literacy, and economic and community development. Preference is also given to students who actively participate in the Interact Club at La Mirada School, and to those who reside in the City of La Mirada.
Please complete this application and submit it along with the required Personal Statement to the Rotary Club of La Mirada for consideration by the deadline of May 3, 2026. All required supporting documents must reach the Rotary Club of La Mirada Scholarship Chair no later than May 8, 2026. You may submit by mail or electronically.
Mail to:
Rotary Club of La Mirada
Attn: Scholarships
PO Box 248
La Mirada, CA 90637-0248
E-mail to:
rotarycluboflamirada@gmail.com
Page 1 of 6

APPLICATION FORM
SECTION 1 – APPLICANT INFORMATION
Contact Information
Name

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:
example@example.com
Phone:
Format: (000) 000-0000.

Volunteer Service (list most recent first)

Rows	Organization	Title or Type of Service	Date From	Date To
1
2
3
4
5
6
7

Leadership Experience (list most recent first)

Rows	Organization	Office or Position	Date From	Date To
1
2
3

Employment Experience (if applicable - list most recent first)

Rows	Employer	Title or Type of Work	Date From	Date To
1
2

Page 2 of 6

RECOMMENDATION #1
Name of Applicant
PART II — To be completed by an academic instructor or employer/supervisor.
1. In what capacity and how long have you known the applicant?

2. How would you rate the applicant in the following areas? If you are unable to evaluate an area, please leave it blank.

Rows	Excellent	Very Good	Average	Below Average
Leadership
Initiative
Seriousness of purpose
Enthusiasm
Adaptability
Maturity
Emotional stability
Public speaking
Community service

3. Any specific examples you'd like to mention of how the applicant has demonstrated these qualities, or other comments?
Name
Title or Position
Signature
Date:

MonthDayYear
Date
Please return completed evaluation to the applicant or mail or e-mail by May 8, 2026 to:
Rotary Club of La Mirada
PO Box 248
La Mirada, CA 90637-0248
E-mail: rotarycluboflamirada@gmail.com
Page 4 of 6

RECOMMENDATION #2
Name of Applicant
PART II — To be completed by an academic instructor or employer/supervisor.
1. In what capacity and how long have you known the applicant?

2. How would you rate the applicant in the following areas? If you are unable to evaluate an area, please leave it blank.

Rows	Excellent	Very Good	Average	Below Average
Leadership
Initiative
Seriousness of purpose
Enthusiasm
Adaptability
Maturity
Emotional stability
Public speaking
Community service

3. Any specific examples you'd like to mention of how the applicant has demonstrated these qualities, or other comments?
Name
Title or Position
Signature
Date:

MonthDayYear
Date
Please return completed evaluation to the applicant or mail or e-mail by May 8, 2026 to:
Rotary Club of La Mirada
PO Box 248
La Mirada, CA 90637-0248
E-mail: rotarycluboflamirada@gmail.com

APPLICANT'S AGREEMENT
I hereby apply for a Rotary Scholarship from the Rotary Club of La Mirada (AKA La Mirada Rotary Club). If I receive a La Mirada Rotary Scholarship, I agree:
1. To help promote Rotary International wherever possible and to permit Rotary to use my name and all photographs and written reports generated through any of my activities related to my scholarship.
2. That I am responsible for gaining admission at my assigned study institution. I must abide by any decisions made by Rotary Club of La Mirada and La Mirada Community Foundation officials concerning my scholarship.
3. That I am expected to embrace Rotary's spirit of volunteerism and engage in volunteer activities from the time of scholarship application, through the educational term, to a post-award commitment in my local community.
4. That my scholarship will not necessarily enable me to earn a degree, diploma, or certificate.
5. That the scholarship funding is for only those items required for my studies (such as tuition and other required fees, books, academic supplies, travel to my study location at the commencement and end of my scholarship year, accommodation and food). I further understand that I will need to seek alternate sources of funding if my costs exceed this amount.
6. That Rotary International, The Rotary Foundation, Rotary Club of La Mirada, the La Mirada Community Foundation, the study institution, and individual Rotary clubs and Rotarians are in no way liable for a scholar's personal welfare or responsible for enabling a scholar to pursue his or her studies beyond the scholarship period. Rotary International, The Rotary Foundation and Rotary Club of La Mirada assume no responsibility or obligation whatsoever beyond providing the amount of the scholarship.
7. All applicants agree that decisions of the Rotary Club La Mirada Scholarship Committee are final. To receive the award, recipients agree to authorize release of scholarship application materials and photograph for use by the La Mirada Rotary Scholarship program promotion and publicity. Applicants agree to release, discharge and hold harmless La Mirada Rotary, the La Mirada Rotary Foundation, Rotary International, La Mirada Community Foundation and their respective subsidiaries, affiliates, officers, directors and employees, from any and all claims or damages arising out of, in any way, their participation in the program. La Mirada Rotary reserves the right to review the conditions and procedures of this scholarship program and to make changes at any time including termination of the program Questions about the application process may be directed to the La Mirada Rotary Scholarship Committee at (657) 214-0158 or by e-mail to La Mirada Rotary at rotarycluboflamirada@gmail.com.
Name of Applicant (please print)
Applicant's Signature
Date

MonthDayYear
Date
Parent or Guardian Signature for Applicant (if under 18)
Print Parent or Guardian Name
Page 6 of 6
Should be Empty:

Florence and Cor Van Dam Memorial Scholarship Application

APPLICATION FORM

SECTION 1 – APPLICANT INFORMATION

Proposed Institutions of Higher Education

RECOMMENDATION #1

PART II — To be completed by an academic instructor or employer/supervisor.

RECOMMENDATION #2

APPLICANT'S AGREEMENT