Application for fall 2015


Part 1 Excel Leadership and Scholarship Initiative Fall 2015



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Part 1

Excel Leadership and Scholarship Initiative



Fall 2015


Biographical Information




Legal name

     

     

     










Last

First

Middle







Preferred first name

     

Former name(s) if any

     

























Mailing address

     










Number and Street







              







City State ZIP Code







E-mail address

     
















Home phone

    /      

Cell phone

    /      










Area Code/Number




Area Code/Number







Social Security Number

     

Gender:

M F

























Place of birth

        

Date of birth

     










City State




Month/Day/Year







Native language if other than English

     

Marital status:

Single Married

























Citizenship:

U.S. citizen Permanent U.S. resident Other

     

Visa

     













Country




Type







Religious faith/Denomination

     

Name of church you attend (if any)

     

























Do you consider yourself to be Hispanic/Latino?

Yes No

If so, specify countries:

     



















In addition, select one or more of the following racial categories to describe yourself:









American Indian or Alaskan Native

Specify tribal affiliation:

     









Asian

Specify countries:

     









Black or African-American

Specify countries:

     









Native Hawaiian or Other Pacific Islander

Specify countries:

     









White

Specify countries:

     



















High school from which you will or did graduate:

     



















How did you hear about Excel for the first time and what was the most helpful source of information about the program?







     







     













Family Information




Father’s full name

     

     

Is he living?

Yes No







Last

First










Home address

     







Number and Street




              

Phone

    /      




City State ZIP Code




Area Code/Number




Occupation / Title

     

Employer

     



















Name of college, if any

     

Degree

     

Year

     

























Mother’s full name

     

     

Is she living?

Yes No







Last

First










Home address

     







Number and Street




              

Phone

    /      




City State ZIP Code




Area Code/Number




Occupation / Title

     

Employer

     



















Name of college, if any

     

Degree

     

Year

     

Father’s e-mail Mother’s e-mail
























With whom do you reside?















In case of emergency, whom should we contact?

     










Please list all of your brothers and sisters below. List oldest sibling first. Use additional sheet if needed.




Name

Age

School or college attended

Grade or year in school




     

     

     

     




     

     

     

     




     

     

     

     




     

     

     

     










Future Plans




Possible area(s) of academic interest/major

     













Possible career or professional plans

     













Do you have interest in a career as a teacher?

Yes No



















Do you plan to live on campus?

Yes No



















Are you interested in studying abroad?

Yes No

If so, in what country?

     
















Academic Honors




Briefly describe any scholastic distinctions you have earned.

     




     




     




     

Extracurricular and Personal Activities

Please list your principal extracurricular, community, church, work and family activities. Include specific events and/or major accomplishments such as musical instruments played, varsity sports participated in and honors earned. Please indicate “x” in the left-hand column if you wish to pursue the activity in college. Use an additional sheet if needed or submit a resume.





Grade level of participation

Approximate

# of hours

spent per week


Positions held or

honors won



(x)

Activity

9

10

11

12



     









     

     



     









     

     



     









     

     



     









     

     



     









     

     

Which of these activities have been most important to you? Briefly explain why.

     

     

     




Educational Information

List all of the high schools, including summer school programs that you have attended from grades 9-12.

List the high school you currently attend first.

Name of school

Location (City, State)

Dates attended

     

     

     

     

     

     

     

     

     




Date of graduation

     

Date of GED

     

Type public private parochial home school

Please list all colleges at which you have taken courses for credit. An official transcript should be sent from each.

Name of college

Location (City, State)

Degree

Dates attended

     

     

     

     

     

     

     

     




Test Information

Scores from the SAT I or ACT are required for admission to CBU or Union University. Scores you have already received should be reported by your school in Part 4. If your school has not received results by the January 16 deadline, you may still apply for Excel but a copy of the exam score report must be received by the Excel office no later than January 20.






Is your school reporting an SAT I or ACT score for you in the Part 4 School Report?

Yes No




If not, what date will you take a test?

     

By what date will you send Excel your score report?

     

Prior Conduct

Have you been convicted of a felony or gross misdemeanor or do you have a court case pending against you at this time? If yes, please attach written explanation with your application.

Yes No

Have you ever been found responsible for a disciplinary violation at an education institution you have attended from 9th grade forward, whether related to academic or behavioral misconduct that resulted in your probation, suspension, removal or expulsion from the institution? If yes, please attach written explanation with your application.

Yes No



Applicant and Parent/Guardian Certification

By our signatures on this form, we certify that:

  • To the best of our knowledge, all statements made in this application are complete and true. We understand that if at any time information in this application is found to be false or inaccurate, it is sufficient cause for rejection or dismissal from Excel.

  • The essays accompanying this application are the applicant’s own work, although they may have been reviewed by parents, teachers, or other advocates.

By our signatures on this form, we understand and agree that:

  • The information submitted on this form will be reviewed by staff at Memphis Leadership Foundation, Union University or CBU and local community-based selection committee members, and outside consultants for the purposes of selection.

  • Excel is committed to increasing knowledge regarding higher education opportunity through research. I may be contacted by Excel staff or outside consultants in the future and asked to participate in research surveys whether or not I am selected for the program.

By our signatures on this form, we consent to:

  • Allow any and all information from this application and from other program-related documents that we may complete to be used with Excel research activities. We understand that findings from research activities may be made available to the public in an aggregated form, though never in a form that would allow the applicant to be identified.

  • Grant the Memphis Leadership Foundation and all Excel partner colleges and universities permission to use photographs and video taken of the applicant during participation in Excel activities for editorial and promotional purposes in any print or electronic media.

  • Release Excel, the Memphis Leadership Foundation Union University or CBU and their respective directors, officers, agents, and employees (collectively “the Releasees”) from liability for any loss, damage, injury, or illness resulting from the applicant’s participation in events sponsored by Excel (including, but not limited to, all program activities and all provided transportation). We promise that we will not institute, prosecute, or in any way aid in the prosecution of any claim, demand, action, or cause of action against any or all of the Releasees.

     




     

Student name (please print)




Parent/guardian name (please print)







     










     

Student signature




Date




Parent/guardian signature




Date



Personal Essays

Deadline: January 16, 2015

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