Application Form Test Page

Please read Scholarship Requirements for Submitting an Application before you begin the application process.

Please note, this application CANNOT be saved. We suggest you print out a PDF and gather the information you need before you start the online form below. Be sure to have information on your sponsoring Rotary club and a digital photo too.

STUDENT SELECTION INFORMATION

First Name*

MIddle Name

Last Name*

Gender*

Email

Student Contact Phone Number

Permanent Street Address*

Permanent City*

Permanent Postal Code*

Permanent Country*

Are you currently living at the permanent address listed?*

Present Address*

Present City*

Present Postal Code*

Present Country of Residence*

Date of Birth*

Age*

Place of Birth*

Country(s) of Citizenship*

Emergency Contact Name*

Relationship*

Emergency Contact Address*

Emergency Contact Email*

Emergency Contact Phone*

Family Information

Father's Name*

Father's Occupation

Father's Full Address

Father's Phone

Father's Email

Mother's Name*

Mother's Occupation*

Mother's Full Address

Mother's Phone

Mother's Email

Number of Brothers*

Please enter a number from 0 to 999.

Ages of Brothers*

Number of Sisters*

Please enter a number from 0 to 999.

Ages of Sisters*

Hidden

Section Break

Have you or any family member been involved in Rotary, Interact, Rotaract or been awarded a GRSP Scholarship?*

Please tell us the name of the family member, the organization and if the member held a position of leadership

Do you have relatives living in the United States?*

Relative's Name*

Relative's Relationship*

Relative's Full Address*

Relative's Phone Number*

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.

About Your Family*

About Your Organizations

Your Strengths*

Your Honors and Awards

Have you served in the military?*

Military where and when*

List your hobbies and leisure time activities:*

How did you hear about Rotary?

What are your aspirations?*

How will Rotary benefit you?*

Have you visited the U.S.A.?*

If yes, when?*

How long was your visit?*

Purpose of visiting US

Reason for visiting US*

Do you smoke?*

Do you have any dietary restrictions?*

Dietary restrictions*

Do you have any allergies, such as to prescription drugs, pets, foods, etc.?*

Allergy List

Do you have any specific needs or restrictions based on your personal religious beliefs?*

Accept if religious needs cannot be met?*

Medical specialist required?*

Special needs*

Prescription drugs?*

List drugs*

Education/Work/Study Plans

List secondary (High School, Gymnasium) and post-secondary (College, University) institutions in the order attended:

Complete First School Name

First School Location*

Attendance From

Month*

Year*

Attendance To

Presently Attending

Month

Year

Graduation Date

Month

Year

Degree Obtained*

Do you have a second school to add?

Complete Second School Name

Second School Location

Attendance From

Month (from 2)

Year

Attendance To

Presently Attending

Month (to 2)

Year

Graduation Date

Month

Year

Degree Obtained*

Do you have a third school to add?

Complete Third School Name

Third School Location

Attendance From

Month

Year

Attendance To

Presently Attending

Month

Year

Are you currently enrolled in the last institution listed above?*

Do you plan to graduate from your current institution?*

Graduation Date

Month

Year

Degree*

Work History

Do you have an employment information to add?*

First Employer*

First Type of Work*

Start Date

Month*

Year*

End Date*

Presently Employed
Enter Month/Year

Month*

Year*

Do you have a second employer to add?*

Second Employer*

Second Type of Work*

Start Date

Month*

Year*

End Date*

Presently Employed
Enter Month/Year

Month*

Year*

Do you have a third employer to add?*

Third Employer*

Third Type of Work*

Start Date

Month*

Year*

End Date*

Presently Employed
Enter Month/Year

Month*

Year*

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?

Do you plan to continue your education in the U.S. after your year in GRSP?*

SAT and TOEFL tests should 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 office in Savannah, Ga. USA. We have 26 participating colleges and universities within Georgia. Some require scores and some do not. The students do not pick the college or the clubs that sponsor them, so the test scores are necessary for the selection process. While we strongly suggest taking your test by October 31, 2022. If you cannot find a test available before then, please put the test date on the application that you have scheduled. Be sure to send the results to Georgia Rotary Student Program for those tests. We are aware that the international dates in early October have filled up and another is not scheduled until December. If the test can be taken in December, that would be advised, as the results would have time to arrive by the end of this year. To meet the English proficiency requirement, schools will accept a TOEFL 74 or SAT Evidence Based Reading & Writing of 480. If there is a delay in the time for the SAT test, we strongly suggest taking the TOEFL before October, if possible, so the club reviewing the application would have an idea of the student’s ability to understand English.

SAT: Date to be taken (MM/DD/YYYY):

Critical Reading (We do not factor in your writing score)

Please enter a number from 0 to 9999.

Math

Please enter a number from 0 to 9999.

TOEFL: Date to be taken (MM/DD/YYYY)

TOEFEL Score

Please enter a number from 0 to 9999.

Certifications and Guarantees

1. ROTARY CLUB ENDORSEMENT MUST BE ON ORIGINAL ROTARY STATIONERY, SIGNED AND SCANED OR SENT BY A CURRENT ROTARY PRESIDENT BY EMAIL TO grsp@grsp.org. Request that the Rotarian writing the recommendation letter send the email directly to grsp@grsp.org and be sure to include your full name in the recommendation letter.

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.

Name of Rotarian*

Email Address of Rotarian*

Fax Number of Rotarian, if available

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 $5,000) to cover all costs not provided by the scholarship.

3. GUARANTEE OF MEDICAL INSURANCE

In submitting this application, I certify that I am in good health, with no physical limitations 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

Applicant's Certification

1. That I have read and fully understand the GRSP Standard Scholarship Agreement. 2. To inform myself about Rotary International (www.rotary.org) 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.  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.  7. That upon my return home, at the conclusion of my 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, withdrawal from institution and course of study prior to expiration of the term of the scholarship, not proficient in the English language, failure to adequately discharge ambassadorial duties, provision of inaccurate information, 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 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. Scholarship funds are sent directly to the institution in two payments, one in fall semester and one in spring semester. Funds are designated and applied to the student’s tuition account.   12. GRSP and the Rotary Club(s) may request a virtual interview. If requested, you must be able to interview virtually. Applicants will be notified by email regarding a decision. Once the recipient is notified and accepts the scholarship agreement, GRSP and the host family will contact the student.   13. 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

Applicant's Photo

The last item we need from you is a recent photo in a jpg format. Please make sure your face is clear, that you are not wearing a hat, face covering, or glasses. Please keep it under 10 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*

Please make sure your photo is under 10 MB in size. File format can be JPG, PNG, or GIF.

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Application Form Test Page

STUDENT SELECTION INFORMATION

Family Information

Section Break

Tell Us About Yourself

Education/Work/Study Plans

Work History

College and Testing Information

Certifications and Guarantees

Applicant's Certification

Applicant's Photo

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