Rotary Scholarship 2013 Guidance Counselor Certification Form

GLENS FALLS ROTARY CLUB
P.O. Box 4702
Queensbury, NY 12804
COMMUNITY SERVICE SCHOLARSHIP GUIDANCE COUNSELOR CERTIFICATION FORM
SPRING 2013
STUDENT APPLICANT’S NAME: ____________________________________________________
APPLICANT’S HIGH SCHOOL: ______________________________________________________
GUIDANCE COUNSELOR: _________________________________________________________
Guidance Counselor’s phone number: ______________________________________________
Guidance Counselor’s e-mail address: ______________________________________________
The section below is to be completed only by the student’s Guidance Counselor. Once signed by the Guidance Counselor, the Certification Form should be forwarded via e-mail to:
David Kisselback (Chairman, Glens Falls Rotary Scholarship Committee)
dkisselback@silverbay.org
Please call David at 518-543-8833 x 201 if you have any questions.
TO: Rotary Scholarship Committee
I hereby certify that the applicant named above has attained at least a “B” average and therefore meets this academic requirement to be considered for the 2013 Glens Falls Rotary Club Community Service Scholarship.
___________________________________________
(Print Guidance Counselor Name)
___________________________________________
(Guidance Counselor Signature)
___________________________________________
(Date)
Children and Grandchildren of Rotarians are NOT eligible to apply for this scholarship.