2024-25 Johnston Ziegler Youth Leadership Award Application
This prestigious scholarship is merit-based and open to all high school seniors in Mecklenburg and surrounding counties. The selected recipient of the Johnston Ziegler Youth Leadership Award will receive a $7,500 educational scholarship to the university or college of their choice. This application must be completed in one sitting and includes the following sections and questions: Personal/Contact Information, High School Activities & Involvement, Short Answer, and an Essay.
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Personal Information
Please fill out the following fields with the applicants information.
Applicant Name
*
First Name
Last Name
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Phone Number
*
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Area Code
Phone Number
Applicant Email
*
example@example.com
Applicant Date of Birth
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Month
-
Day
Year
Date
How did you hear about this scholarship?
*
Guardian/Caregiver Information
Please fill out the following fields with the applicant's guardian or caregiver information.
Guardian Name
*
First Name
Last Name
Relationship to Applicant
*
Guardian Phone Number
*
-
Area Code
Phone Number
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School Information
If you do not have a weighted GPA, type "Not Applicable" in the box.
High School Name
*
Most Recent Weighted GPA
*
Most Recent Unweighted GPA
*
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Community Involvement
Please list community service activities you have participated in during high school and the total hours you spent involved/volunteering.
Community Involvement
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Activity
Total Hours
Duration/Frequency
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Extracurriculars
Please list extracurricular activities you have participated in during high school and the total hours you spent involved/volunteering.
Extracurriculars
*
Activity
Office Held
Dates Participated
1
2
3
4
5
Honors & Awards
Please list honors or awards that you have received.
Honors & Awards
Honor/Award
Description
Date Recieved
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5
Additional Information
Please use the space below for any additional information about your community involvement, awards, or extracurriculars that you would like the selection committee to know.
Additional Information
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Short Answer Questions
Please respond to the following short-answer questions. Responses are limited to 100 words.
Who is your role model and why?
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0/100
Describe what you think the greatest health issue for adolescents is and why?
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0/100
How have you demonstrated resilience in difficult situations?
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0/100
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Essay
Please respond to the following essay question. Your responses must be at least 350 words, but no more that 500.
How have you contributed to your community through leadership, advocacy, or service during high school? What have you gained through these experiences?
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0/500
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Pledge & Media Consent
The Johnston Ziegler Scholarship recognizes teens doing exemplary work and serving as role models in their communities. We believe that a healthy, safe, and successful teen is also an alcohol, tobacco, and drug-free teen. To be eligible for this award, teens cannot be using alcohol or drugs. To assure this, we ask that all applicants complete our pledge to be alcohol, tobacco, and other drug free. I pledge that I do not drink alcohol, misuse prescription or over-the-counter medicine, or use illegal substances. I understand that the information submitted will be utilized in the decision-making process and may also be used in media, internet, and other forms of public communication. This application, including the attached essay, is my own work or formally cited from other sources. I affirm that the information contained herein is true and accurate to the best of my knowledge and belief. I hereby grant Teen Health Connection permission to use, re-use, exhibit, distribute, or publish my and/or my child’s testimonials, images, artwork, portraits, pictures or videos for any Teen Health Connection purpose including but not limited to Teen Health Connection illustrations, art, videos, promotional materials, editorials, advertising, publications, websites or web content, all without any compensation. I understand that any images, videos or artwork may be used at exhibits and may identify me and/or my minor child. I relinquish any right that I may have to inspect, examine or approve any completed product or products or any written or electronic copy or other printed matter that may be used in conjunction with any of the foregoing. I understand and agree that all materials containing the images or artwork of me and/or of my minor child shall become the property of Teen Health Connection. I hereby release, discharge and agree to forever hold harmless Teen Health Connection, its legal representatives or assigns, and all persons or entities functioning under its permission or authority from all and any claims, demands or causes of action ensuing from or in connection with the use or publication of any of the foregoing including without limitation any claims for libel or invasion of privacy. This authorization and release shall inure to the benefit of the legal representatives, licensees and assigns of Teen Health Connection and shall be binding upon me and upon my estate, my heirs and my legal representatives. I have read and fully understand the content, meaning and impact of the forgoing and represent that I am the individual named below. I agree that I am over the age of majority or that I am the parent or legal guardian of the minor child named below, am over the age of majority, and hereby consent to the foregoing on behalf of such minor child named below.
Applicant Name
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First Name
Last Name
Today's Date
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Month
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Day
Year
Date
Applicant Signature
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Guardian Name
*
First Name
Last Name
Today's Date
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Month
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Day
Year
Date
Guardian Signature
*
Submit
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