The Scholars Application

The Scholars Application Form

SPREADING KNOWLEDGE
PERSONAL INFORMATION
Applicant's Last Name
Applicant's First Name
Date Of Birth

MonthDayYear
Date
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parents Name

Last NameFirst Name
Primary Contact Cell Number

Area CodePhone Number
Parents Name

Last NameFirst Name
Secondary Contact Cell Number

Area CodePhone Number
Primary Contact's E-mail
EMERGENCY CONTACT INFORMATION
Primary Emergency Contact

First NameLast Name
Primary Emergency Contact Cell Number

Area CodePhone Number
Primary Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Emergency Contact

First NameLast Name
Secondary Emergency Contact Cell Number

Area CodePhone Number
Secondary Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL INFORMATION
Hospital/Clinic Preference
Physician Name
Physician Phone Number
Allergies/Special Health Conditions
Applicant 'Child' Name

First NameLast Name
Applicant Signature
Parent Name

First NameLast Name
Applicant Signature
GIVE BRIEF INFORMATION ON YOURSELF BY ANSWERING THE FOLLOWING QUESTIONS.
Why do you want to be a scholar?
What is a team player? Are you a team player?
What is a leader? How are you a leader?
What are three hobbies you enjoy doing and why?
Do you want to be an Entrepreneur? What type of business would you like to own?
Should be Empty: