GRSP Scholarship Application

SECTION I - PERSONAL DATA

Last Name       First Name                                   Middle Initial

Permanent Street Address:

City       Zip Code

Country                                   Country of Citizenship

Place of Birth - City / Country

Birthday (MM/DD/YYYY)

Fax Number      E-mail

Gender

Father's Name                                    Occupation

Father's Full Address

Father's Phone Number
(you must input the father's or the mother's phone number or both)

Mother's Name                                    Occupation

Mother's Full Address

Mother's Phone Number

Brothers                               /             Sisters                               /
            Number /           Ages                                    Number /          Ages

RELATIVES LIVING IN THE UNITED STATES:

Name     Relationship

Full Address (Street, City, State, Zip)

Relative's Phone Number (include area code)

List hobbies and leisure time activities:

List sports in which you are proficient:

List musical instruments you play, including singing:

List societies or student organizations:

List honors or awards:

Should you receive a scholarship, Georgia Rotarians will want to know more about your family and how your family has helped shape your life. In 250 characters or less, please tell us about your family.

Have you visited the U.S.A.?

If yes, when?        How long was your visit?

Purpose:

If other, explain:

Do you smoke?

Do you have any diet restrictions?

If so, what are your diet restrictions?

Have you or any family member been involved in Rotary, Interact, or Rotaract?                                 If yes, which one?

Do you have any allergies, such as to drugs, pets, foods, etc.?

   If yes, please list your allergies:

Have you served in the Military?

   If yes, where and when?

Do you have any special needs due to religious practice?

   If so, are you willing to accept this scholarship if these needs cannot be met?

Do you have any ongoing physical or mental conditions that would require the need for a doctor, psychiatrist, dentist or other specialist?

If yes, does this condition require any special needs such as a wheelchair or audio-visual equipment?

List any prescription drugs that you have taken in the past year:

SECTION II - EDUCATION / WORK / STUDY PLANS

List secondary (High School, Gymnasium) and post-secondary (College, University) institutions in the order attended.

Complete First School Name

Location (City, Country)

Attendance (MM/YYYY) From                              To

Graduation Date (MM/YYYY)                                Degree Obtained

Complete Second School Name

Location (City, Country)

Attendance (MM/YYYY) From                             To

Graduation Date (MM/YYYY)                               Degree Obtained

Complete Third School Name

Location (City, Country)

Attendance (MM/YYYY) From    To

Graduation Date (MM/YYYY)      Degree Obtained

Are you currently enrolled in the last institution listed above?

Do you plan to graduate from your current institution?

     If yes, when? (MM/YYYY)

List work history:

Employer      Type of Work

From (MM/YYYY)    To (MM/YYYY)

Second Employer      Type of Work

From (MM/YYYY)    To (MM/YYYY)

Third Employer      Type of Work

From (MM/YYYY)    To (MM/YYYY)

Fourth Employer      Type of Work

From (MM/YYYY)    To (MM/YYYY)

List the courses you desire to study in a college or university in Georgia:

If a GRSP Scholarship cannot obtain the course work you prefer toward your goal of a degree, would you still be interested in receiving the scholarship?

Do you plan to continue your education in the U.S. after your year in GRSP?

What are your employment plans after your education is completed?

TESTS: (See Requirements for Submitting an Application. TESTS MUST BE TAKEN BY 10/31.)
Undergraduate applicants must take the SAT and TOEFL. Applicants from non-English speaking countries are required to take the TOEFL. If you have already taken the tests, please list the dates taken and the scores. ORIGINAL test scores must be furnished before a scholarship can be awarded. If you have NOT taken the tests, please indicate the DATES YOU HAVE APPLIED TO TAKE SUCH TESTS. Submit your application regardless of the status of the test dates. TEST DATES MUST BE APPLIED FOR AND ALL FEES PAID BY THE APPLICANT.

SAT           Date to be taken (MM/DD/YYYY)    Critical Reading                                 Math
                                                                                               (We do not factor in your writing score)

TOEFL       Date to be taken (MM/DD/YYYY)      Score

Graduate applicants are required to take the GRE or the GMAT, but are NOT required to take the SAT. Applicants from non-English speaking countries are required to take the TOEFL. If you have already taken the tests, please list the dates taken and scores. ORIGINAL test scores must be furnished before a scholarship can be awarded. If you have NOT taken the tests, please indicate the DATES YOU HAVE APPLIED TO TAKE SUCH TESTS. Submit your application regardless of the status of the test dates. TEST DATES MUST BE APPLIED FOR AND ALL FEES PAID BY THE APPLICANT.

GRE            Date to be taken (MM/DD/YYYY)    Verbal                           Qual

or GMAT     Date to be taken (MM/DD/YYYY)      Score

TOEFL        Date to be taken (MM/DD/YYYY)      Score

Please state, in 250 characters or less, why you are applying for a Georgia Rotary Student Scholarship. This should be in the form of a short essay detailing special interests or specific purposes for applying.

SECTION III - CERTIFICATIONS AND GUARANTEES

1. ROTARY CLUB ENDORSEMENT (MUST BE ON ORIGINAL ROTARY STATIONERY AND SIGNED BY A CURRENT ROTARY PRESIDENT)

Sponsoring Rotary Club

Full Address of Club

District of Sponsoring Rotary Club

hereby endorses

as an applicant for a Georgia Rotary Student Program Scholarship and acknowledges that the above named applicant is a person of high ideals, good moral character, superior academic ability, outstanding leadership qualities, and will represent to the Rotarians of the State of Georgia the Ideas of Rotary. I have personally interviewed this applicant in order to sign this endorsement.

Please type or print legibly complete name and address of Rotarian other than family member to whom correspondence to above club should be sent:

Fax     E-mail
               (include city code)

2. GUARANTEE OF TRANSPORTATION / ADDITIONAL FUNDS

I,
                         Name

                         Relationship to Applicant

hereby guarantee to the Georgia Rotary Student Program that                           has adequate financial resources to provide transportation both to and from his (her) home country to the State of Georgia, USA, should a scholarship be awarded. I further guarantee that this applicant will have adequate additional funds (approximately $3,000) to cover all costs not provided by the scholarship.

3. GUARANTEE OF MEDICAL INSURANCE

(a) In submitting this application, I certify that I am in good health, with no physical deformities which might interfere with a year's study and travel, and

(b) Further, I relieve the Georgia Rotary Student Program, Inc., of any financial responsibility for any accident, injury, illness or death. I also agree to obtain an insurance policy, at my own expense, for hospitalization and medical resulting from any accident, injury, illness or from accidental death and dismemberment. I agree that the insurance policy shall be in force from the date of departure through the date upon return to my home.

SECTION IV - APPLICANT'S CERTIFICATION

I HEREBY AGREE (UPON RECEIVING A SCHOLARSHIP) TO:

1. To inform myself about Rotary in cooperation with my sponsoring Rotary Club or District Governor prior to departing from my home community, and to utilize the opportunities presented by the scholarship to work for the advancement of international understanding and goodwill at home and abroad.

2. To reply to correspondence from my host Rotary Family as soon as possible and notify The Georgia Rotary Student Program Office and host club of my travel plans.

3. To maintain a high level of achievement in my program of study and to make no change in my field of study without notifying The Georgia Rotary Student Program Office.

4. To accept such speaking engagements which would be helpful in carrying out the purpose of the Georgia Rotary Student Program.

5. To submit on time a written report to The Georgia Rotary Student Program on my year of study.

6. Upon my return home at the conclusion of my year of study, to visit and speak to Rotary Clubs and other groups in order to discuss my experiences as a Georgia Rotary Student Program Scholar and to create a better understanding of the country in which I studied.

7. That my scholarship may be revoked for any of the following reasons: my inability to secure admission to an institution approved by The Georgia Rotary Student Program, low level of educational achievement, evidence of misconduct, change of course of study program without consent of the Georgia Rotary Student Program, withdrawal from institution and course of study prior to expiration of the term of the scholarship, deficient knowledge of the language, failure to adequately discharge ambassadorial duties, or any contingency which prevents me from fulfilling all the obligations of the scholarship.

8. That I obtain at my expense, insurance coverage, valid against sickness, accidents, injury or accidental death in the amount specified or above these minimum levels: Benefits of the insurance required will be a minimum of US $100,000 for medical/hospitalization care resulting from illness or accident, plus a minimum of US $10,000 for accidental death and dismemberment. Scholarship recipients must be insured from date of departure to date of returning home.

9. That for any reason I find it necessary to return to my home before the end of my year, I must notify immediately the Georgia Rotary Student Program office, my Trustee and the Clubs sponsoring me.

10. That the primary purpose of my scholarship is to contribute to international understanding through study and not necessarily to enable me to earn a degree, diploma or certificate.

SECTION V - APPLICANT'S PHOTO

The last item we need from you is a photo in a jpg format. Please keep it under 1 MB of memory and label it with your last name, then your first name, such as ComerJanis.jpg. You may upload it using the field below.

Please print a copy of this form for your files before clicking SUBMIT!