Students around the world are welcome to submit an application to study in Georgia, USA, for one year on a scholarship from the Georgia Rotary Student Program. We are now accepting applications for the 2018-2019 school year. IMPORTANT SUBMISSION GUIDELINES Before starting this application, please make sure that your browser has the most current version of Java. Please read Scholarship Requirements for Submitting an Application before you begin the application process. SECTION I - STUDENT SELECTION INFORMATION First Name: * Middle Name: Last Name: * Gender: * -Select Your Gender- Male Female E Mail Address: * Permanent Street Address: * Permanent City: * Permanent Postal Code: * Permanent Country: * Are you currently living at the permanent address listed? * Yes, I am living at the permanent address listed above. No, I am currently living at another address. Present Address: * Present City: * Present Postal Code: * Present Country: * What is your date of birth? Birth Day: * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Month: * January Februrary March April May June July August September October November December Birth Year: * 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Place of Birth: * Country(s) of Citizenship: * Emergency Contact Name: * Relationship: * Emergency Contact Address: (Street, City, Country, Zip) * Emergency Contact Email: * Contact Phone: * FAMILY INFORMATION: Father's Name: * Father's Occupation: * Father's Full Address: (Street, City, Country, Zip) Father's Phone Number: Father's E Mail Address: Mother's Name: * Mother's Occupation: * Mother's Full Address: (Street, City, Country, Zip) Mother's Phone Number: Mother's E Mail Address: Number of Brothers: * Ages of Brothers: * Number of Sisters: * Ages of Sisters: * Have you or any family member been involved in Rotary, Interact, Rotaract or been awarded a GSRP Scholarship? * No, members of my family are not affiliated with any of the organizations. Yes, members of my family are affliliated with one of the organizations. Please tell us the name of the family member, the organization and if the member held a position of leadership: Do have relatives living in the United States? * No, I do not have relatives living in the U.S. Yes, I do have relative living in the U.S. Relative's Name: * Relationship: * Full Address: (Street, City, Country, Zip) * Relative's Phone Number (include area code): * TELL US ABOUT YOURSELF: This is the essay portion of the application. Your responses will help the Rotarians learn about your life as an individual. The space is limited, so take some time preparing your answer. It is important to write in complete sentences using proper upper and lower case. In 200 words or less, please tell us about your family. How have they helped shape the conception of who you are, your values, goals and dreams? What does your family enjoyed doing together? * In 100 words or less, please tell us about societies or student organizations you are involved with: In 100 words or less, please describe how you have shown or taken a leadership position in your school or any other civic and academic organizations: * In 100 words or less, please tell us what you consider your major strengths: * In 100 words or less, please tell us about honors or awards you have received: Have you served in the Military? * No, I have not served in the Military. Yes, I have served in the Military. If yes, where and when: * List your hobbies and leisure time activities: * List any sports in which you are proficient: List any musical instruments you play, including singing: In 100 words or less, please tell us how you heard about the Georgia Rotary Student Program: * In 100 words or less, please state why you are applying for a Georgia Rotary Student Scholarship. Please detail special interests or specific purposes for applying: * In 100 words or less, please describe how you envision your year as a GRSP Scholar benefiting you in your future community/world leadership endeavors: * In 100 words or less, please describe what your your career and lifestyle aspirations after you complete your education: * Have you visited the U.S.A.? * No, I never visited the U.S.A. Yes, I have visited the U.S.A. If yes, when? * How long was your visit? * Purpose: * Student Family Tourist Other If other, please explain: * Do you smoke? * Non-smoker Smoker Do you have any diet restrictions? * No, I do not have diet restrictions. Yes, I do have diet restrictions. If so, what are your diet restrictions? * Do you have any allergies, such as to drugs, pets, foods, etc.? * No, I do not have allergies. Yes, I have allergies. If yes, please list your allergies: * Do you have any special needs due to religious practice? * No, I do not have religious needs. Yes, I have religious needs. If so, are you willing to accept this scholarship if these needs cannot be met? * No, I will not accept the scholarship Yes, I will still accept the scholarship Do you have any ongoing physical or mental conditions that would require the need for a doctor, psychiatrist, dentist or other specialist? * No, I do not require a specialist. Yes, I require the help of a specialist. If yes, does this condition require any special needs such as a wheelchair or audio-visual equipment? * Have you taken prescription medication within the past year? * No, I have not taken prescription drugs within the past year. Yes, I have taken prescription drugs within the past year. List any prescription drugs 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 From Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 Attendance To To Presently Attending Enter Month/Year Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Graduation Date Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Degree Obtained: Do you have a second school to add? * No, I do not have another school to add. Yes, I have another school to add. Complete Second School Name: * Location (City, Country): * Attendance From Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 Attendance To Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Graduation Date Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Degree Obtained: Do you have a third school to add? * No, I do not have another school to add. Yes, I have another school to add. Complete Third School Name: * Location (City, Country): * Attendance From Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 Attendance To Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Graduation Date Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Degree Obtained: Are you currently enrolled in the last institution listed above? No, I am not enrolled in the last school. Yes, I am currently enrolled in the last school. Do you plan to graduate from your current institution? Yes, I plan to graduate from this school. No, I do not plan to graduate from this school. If yes, when? Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2017 2018 2019 2020 2021 2022 2023 2024 LIST WORK HISTORY: Do you have an employment information to add? * No, I do not have employment information to add. Yes, I do have employment information to add. Employer: Type of Work: From: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 To: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Do you have a second employer to add? No, I have no other work history to add. Yes, I have more work history to add. Second Employer: Type of Work: From: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 To: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Do you have a third employer to add? No, I have no other work history to add. Yes, I have more work history to add. Third Employer: Type of Work: From: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2010 2011 2012 2013 2014 2015 2016 2017 To: Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 COLLEGE AND TESTING INFORMATION List the courses you desire to study in a college or university in Georgia, USA: 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? Yes, I would accept the scholarship No, I would not accept the scholarship Do you plan to continue your education in the U.S. after your year in GRSP? No, I do not plan to continue my education in the U.S. Yes, I plan to continue my education in the U.S. TESTS SAT and TOEFL tests must be taken by October 31. Receipt of original test scores is mandatory for the evaluation of your application and scholarship award. Applicants from non-English speaking countries are required to take the TOEFL test. If you have taken the tests indicate the dates of the test and the scores below. If you have NOT taken the tests, please indicate the dates you have applied and scheduled to take the tests below. Test applications and associated fees are the responsibility of the Applicant. Submit your application regardless of the status of the test dates. You may use the GRSP Code of 5285 and the results will be sent directly to the GRSP home office in Savannah, Ga. USA. SAT: Date to be taken (MM/DD/YYYY): Critical Reading (We do not factor in your writing score): Math: TOEFL: Date to be taken (MM/DD/YYYY): TOEFEL Score: SECTION III - CERTIFICATIONS AND GUARANTEES 1. ROTARY CLUB ENDORSEMENT (MUST BE ON ORIGINAL ROTARY STATIONERY AND SIGNED BY A CURRENT ROTARY PRESIDENT) Request that the Rotarian writing the recommendation letter return it to you in a sealed envelope for your delivery to the GRSP home office or provide them a postage paid envelop and the address of the GRSP home office for their use. Sponsoring Rotary Club: * Full Address of Club: (Street, City, Country, Zip) * District of Sponsoring Rotary Club: * hereby endorses (your name): * 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, exceptional 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. Complete name and address of Rotarian other than family member to whom correspondence should be sent: Fax Number of Rotarian: Email Address of Rotarian: * 2. GUARANTEE OF TRANSPORTATION / ADDITIONAL FUNDS I, Name of Adult Guarantor: * Relationship to Applicant: * hereby guarantee to the Georgia Rotary Student Program that Your Name: * has adequate financial resources to provide transportation both to and from his or 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 an 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 expenses resulting from any accident, 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. Agreement: I do not agree to the above I agree to the above SECTION IV - APPLICANT'S CERTIFICATION I hereby agree: 1. That my inability to secure admission into an institution approved by The Georgia Rotary Student Program as selected by my sponsoring Rotary Club(s) will result in revocation of the scholarship. 2. To inform myself about Rotary International in cooperation with my home sponsoring Rotary Club or Rotary District Governor prior to departing my home community. 3. To reply to correspondence from my host Rotary Clubs as soon as possible and notify both the GRSP home office in Savannah, Ga. USA and my host Rotary Clubs of my travel itinerary to Georgia, USA. 4. To maintain a high level of achievement in my program of study and to make no changes in my field of study without notifying the GRSP home office and my host Rotary Club. 5. To accept appearance and speaking engagement invitations that would be beneficial in advancing and promoting the GRSP program both while in Georgia and after I return home. 6. To obtain and maintain health insurance as per the Student Application Guidelines paragraph 8. 7. That upon my return home, at the conclusion of my year of study, to visit and speak to Rotary Clubs and other groups in my area to share my experiences as a GRSP Scholar and create a better understanding of the USA. 8. That my scholarship may be revoked for any of the following reasons: Evidence of low educational achievement, misconduct, change in course of study 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 English language, failure to adequately discharge ambassadorial duties, possession, distribution or use of any illegal controlled substance, any contingency which prevents me from fulfilling all the obligations of the scholarship, any social media postings deemed offensive, inflammatory, or obscene. All of the above infractions are reviewed by the GRSP staff and Trustees for final decision by the GRSP Chairman. 9. That for any reason I find it necessary to return home before the end of my year or otherwise withdraw from the institution, I shall immediately notify The GRSP home office, my Trustee, and sponsoring Rotary Club(s). 10. I understand that the GRSP Scholarship is primarily an ambassadorial scholarship with an emphasis on education and I will do my best to utilize the opportunities presented by the scholarship to further the GRSP goal of promoting world peace through understanding both at home and abroad. 11. By signing below, I authorize the Georgia Rotary Student Program to obtain such information about me and authorize the release of such information to GRSP as part of this application process and I do hereby waive any claim of breach of privacy or any other claim that I may have regarding the release of such information to GRSP, its employees, agents, officers, and trustees, and all Georgia Rotarians involved in the student selection process. I am also aware that GRSP, its employees, agents, officers, and trustees may have to disclose my personal information to third parties as required by law. If selected, while I am in Georgia I will provide a copy of my grades and class schedule to GRSP which may be released to determine my eligibility to remain a participant in the Program. I also understand that it may be necessary for me to sign additional specific releases as part of the application process, or if selected while I am a student in the program, and I agree to sign such releases as requested by GRSP. Agreement: I do not agree to the above. I agree to the above. 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. Make sure that the photo is loaded onto the application in the proper layout configuration - (not sideways or upside down). Photo Upload: Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 8.39MB The photo must be in .jpg or .jpeg file format. Please help us control spam Application Printing Instructions: Once the Submit button is selected, you should receive a confirmation page. The Confirmation Page will redirect your browser to the Print Page where the application should be printed for your records as well as a copy to mail to the GRSP Office.