REBEKAH ASSEMBLY OF CALIFORNIA
Independent Order of Odd Fellows
SCHOLARSHIP APPLICATION
2015-2016
This application must be received by the Rebekah Assembly Office on or before March 30, 2016.
No applications received after the final date will be accepted. Please print or write legibly.
1. Name in full ______________________________________________________
(Last)
(First)
(Middle)
2. Home Address _____________________________________________________
(Street, Route or Box Number)
(Telephone No.)
_____________________________________________________
(City)
(State)
(Zip)
3. Date of Birth______________________________________________________
(Month) (Day)
(Year)
(Marital Status) (Sex)
4. Parent or Guardian’s name in full______________________________________
5.__________________________________________________________________
(Address of Parent or Guardian if different from your own)
6. _________________________________________________________________
(Father’s Occupation)
(Place of employment)
7. _________________________________________________________________
(Mother’s Occupation)
(Place of employment)
8. _________________________________________________________________
(Guardian’s Occupation)
(Place of employment)
9. Other members of the immediate family living at home.
__________________________________________________________________
(Name)
(Age)
(Relationship)
10. Applicant must be a member in good standing or a relative, or a relative of a deceased member
in good standing at time of death, of a Rebekah Lodge in the Jurisdiction of California
___________________________________________________________________
(Name of Member)
(Relationship)
A letter from the Rebekah Lodge, under the Seal of the Lodge must be included stating the status
of the member.
In the case of a Theta Rho or Junior Lodge, good standing shall be affirmed by the secretarial
officer and attested by the Advisor.
(Name, Number and location of Lodge, Club or Junior Lodge)
11. List last High School and Colleges attended. List dates of attendance, graduation, and present
school.
12. What college or university are you planning to enter or attending?
____________________________________________________________________
13. When? _____________ Major Course of Study__________________________
14. For what occupation are you preparing? _________________________________
15. Will you work while attending college? __________________________________
16. Have you been or are you now a recipient of any other Scholarships?
__________________________________________________________________
17. Write a short statement concerning your aims and goals, your reason for selection of
your major, a little about yourself personally and how financial help would be of value to
you.
18. List community service, clubs (school or community) church, athletics and any special
interests. Include dates, if an officer what office.
19. Arrange for three sealed letters of recommendation of your character, ability and
financial needs. These must be attached to your application and sent to the Committee.
You must have a statement from a teacher, minister, doctor or other person in the
community, signed and dated.
20. Send the following data to Marilyn Nichols, Chairman.
a. Completed application
b. Verification of Rebekah membership: by letter, under the seal of the lodge or
verification of Theta Rho or Junior Lodge membership, by letter affirmed by the
secretarial officer and attested by the Advisor.
c. Complete transcript of grades from all High Schools and Colleges attended.
d. Your statement of your aims.
e. Three sealed letters of recommendation.
Mail to: Marilyn Nichols
778 Harold Smith Drive
Tracy, CA 95304
(209) 522-8344
21. Winners & Alternates will be notified following May 2016 RA Session
22. I certify that the information provided in this application is true to the best of my
knowledge.
________________________________________ (Applicant signature) Date ___________