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LaSalle Kin Club
2015 Student Bursary Application Form
Deadline: April 30, 2015
Eligibility
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Be a Canadian citizen or landed immigrant and reside in the LaSalle Community
Plan to register as a full-time student in the 2015-2016 school year at a recognized postsecondary institution.
Demonstrate high ideals and qualities of citizenship, and not have previously received a
bursary from the LaSalle Kin Club.
Application Procedure
Complete the current application form and send to:
(by mail) LaSalle Kin Club, P.O. Box 37007, LaSalle, ON N9H 2N8
(by email) lakinclub@gmail.com
Attach a copy of proof of citizenship
Funding will be awarded after proof of tuition payment is forwarded to the LaSalle Kin Club
Privacy Statement and Agreement
By completing and authorizing this application, you consent to the use of your personal
information for processing of the application, publication of your name and photo in media and
use for Kin Club promotional purposes.
I herby acknowledge and agree to the above privacy statements and use of my personal
information by the LaSalle Kin Club. I further acknowledge that the information in this
application is true and any negligence on my behalf could result in disqualification of bursary
eligibility.
Signature of Applicant: ________________________________ Date: _____________________
(Or of parent/guardian if applicant is not age of majority)
2015 LaSalle Kin Club Bursary Application
(Must Be A LaSalle Resident and Currently In Grade 12)
Personal Information
Last Name: _________________________
First Name: _________________________
Permanent Address: ______________________________________________________
_______________________________________________________________________
Phone Number: __________________________________________________________
Email Address: __________________________________________________________
Program of Study
Name of Post Secondary Institution planning to attend: __________________________
______________________________________________________________________
Program/Area of Study: ___________________________________________________
Current School Attending: _________________________________________________
Overall yearly average (percent): Grade 9: _____ Grade 10: _____ Grade 11: _____
Financial Information
List your gross income for the past three (3) years
2011: _________________ 2012: _______________ 2013: _________________
Indicate your parent’s/guardian’s combined income from line 150 on the most recent T1 General tax
form as per Revenue Canada.
Combined income: ______________________________
Personal Background
On a separate sheet of paper(s) please list/answer the following:
1) List your extra-curricular activities for the past three years.
2) List your community service and volunteer activities for the past three years.
3) List your current/previous places of employment including job description for the past three years.
4) What are your plans for your future career or profession?
5) What is your opinion as to why it is important to be an active volunteer in your community (Maximum
of 250 words)?