2017 Jumpstart MS Scholarship Application

Transcription

1 2017 Jumpstart MS Scholarship Application TYPE OR NEATLY PRINT ALL INFORMATION EXCEPT SIGNATURES Application postmark Completeness and neatness ensure your application will be reviewed properly. deadline: Feb. 3, 2017 All written comments must be in applicant s own words. APPLICANT Last Name First Middle Initial DATA Permanent Home Mailing Address Apt # City State Zip Code Telephone ( ) Address Date of Birth: Month Day Year Please check one of the following (you must fit one of the following categories to qualify); I am a 9 th grader who has MS. I am a 9 th grader & have a parent who has MS. NOTE: Verification of diagnosis of MS of yourself or your parent is required of all recipients. Please attach verification of diagnosis with your application (e.g. letter of diagnosis from physician, faxed medical statement, copy of prescription, etc.) Please indicate your status. (for statistical purposes only) Male Female American Indian/Alaska Native Black/African American Multi-racial White Asian Hispanic/Latino Native Hawaiian/Pacific Islander Awards are granted without regard to race, color, creed, religion, age, gender, national origin, or sexual orientation. PARENT OR GUARDIAN INFORMATION Last Name First Middle initial Address Relationship to applicant Day Telephone ( ) Address Fax Number ( ) HIGH School Name High School Graduation Date Month Year SCHOOL DATA City State Telephone ( )

2 Applicant Name All responses must be written by the applicant or the application will be disqualified. ACTIVITIES AWARDS AND HONORS List all school activities in which you have participated (e.g. student government, music, sports, etc.) List all community activities in which you have participated without pay (e.g. Boy/Girl Scouts, hospital volunteer, Special Olympics, Board Member, Mentor, Recorder). Note any specials awards, honors and offices held. Activity No. of Years Participating Special Awards, Honors Offices Held Make a brief statement about your most meaningful activities, of what activities are you most proud?

3 Applicant Name All responses must be written by the applicant or the application will be disqualified. GOALS AND ASPIRATIONS Make a brief statement of your plans as they relate to your educational and career objectives and goals. SPECIAL CIRCUMSTANCES Please describe all special circumstances our reviewers should consider when reviewing your application. Such circumstances might include family care or financial responsibility, personal or family challenges, and/or other circumstances. (Your personal statement does not replace this response.) PERSONAL ESSAY On a separate sheet of paper please provide a one-page essay (single-spaced, 850 words maximum) on the following statement. Please describe the impact MS has had on your life - how has it affected you? How has your life changed since MS has been a part of it? How are you contributing to the MS movement, now and in the future?

4 Applicant Name APPLICANT REFERENCE #1 To the Applicant: This section is required and must be completed in the format provided. If incomplete, your application will not be evaluated. The applicant s achievements reflect his/her ability extremely very moderately not The applicant s ability to set realistic and attainable goals excellent good fair poor The quality of the applicant s commitment to school and/or community excellent good fair poor The applicant is able to seek, find, and use learning resources extremely very moderately The applicant demonstrates curiosity and initiative extremely very moderately The applicant demonstrates good problem solving extremely very moderately skills, follows through, and completes tasks not not not The applicant s respect for self and others excellent good fair poor Please add any comments that will be helpful in reviewing this applicant s qualifications: Reference Provider s Name Relationship to applicant Title (if applicable) Date Telephone ( ) Signature

5 Applicant Name APPLICANT REFERENCE #2 - TO BE COMPLETED BY A NON-RELATIVE (for example, a teacher, coach, school advisor) To the Applicant: This section is required and must be completed in the format provided. If incomplete, your application will not be evaluated. The applicant s achievements reflect his/her ability extremely very moderately not The applicant s ability to set realistic and attainable goals excellent good fair poor The quality of the applicant s commitment to school and/or community excellent good fair poor The applicant is able to seek, find, and use learning resources extremely very moderately The applicant demonstrates curiosity and initiative extremely very moderately The applicant demonstrates good problem solving extremely very moderately skills, follows through, and completes tasks not not not The applicant s respect for self and others excellent good fair poor Please add any comments that will be helpful in reviewing this applicant s qualifications: Reference Provider s Name Title Telephone ( ) Signature Organization Date

6 Applicant Name APPLICATION CHECKLIST The student is responsible for submitting all materials. Late applications will not be processed. (Do not leave your application with a school official or other official to submit.) Incomplete applications will not be evaluated. This application becomes complete and valid only when the National Multiple Sclerosis Society, Upper Midwest Chapter has received all of the following materials: (Please submit all materials in one envelope) Student Application Applicant Reference #1 Applicant Reference #2 Verification of MS Diagnosis Personal Essay Media Release Form All materials must be addressed to: National Multiple Sclerosis Society, Upper Midwest Chapter Jumpstart MS Scholarship Program, Attn: Krista Harding th Avenue S. Minneapolis, MN Postmark deadline: February 5, 2016 Please send me more information about: National MS Society programs for teens who have a parent with MS MS Youth Camp Other:

7 CERTIFICATION The National Multiple Sclerosis Society has the sole responsibility for selecting recipients based on criteria as set forth in the program s description, information at MSSociety.org website, and other written material. This application becomes the property of The National MS Society. (It is recommended that you keep a copy for your files.) I acknowledge decisions of the National Multiple Sclerosis Society are final. I certify that I meet eligibility requirements of the program and the information is complete and accurate to the best of my knowledge. If requested, I will provide proof of information. Falsification of information may result in termination of any award granted. Applicant s Signature Parent/Guardian s Signature Date Date

8 Media Release Form (To be completed by parent/guardian) Name Address Telephone This is to confirm that I hereby grant my child, who is under the age of 18, permission to participate in the National MS Society Jumpstart MS Scholarship program. I hereby, and for my child, waive and release any and all rights and claims against the National Multiple Sclerosis Society, its directors, officers, employees, agents and chapters. Consent is also given to use my child s name, picture or portrait, likeness, writings and biographical information, audio tape and/or videotape recordings, sound or silent motion pictures of my child in any media for editorial, educational, promotional and advertising purposes including for the solicitation of contributions and furtherance of the corporate objectives of the National Multiple Sclerosis Society s website or any other electronic media format. Signature Witness Name Address Witness Signature City State Date