Mary Richey Global Volunteer Award
STUDENT APPLICATION
*All applications, letters of recommendation, and essays must be submitted to Mrs. Ganje in the guidance office on or before 3:30 P.M. on Monday, May 16, 2016.
A completed application must include the following:
1.)This form with all answers complete
2.)Threeletters of recommendation from adults unrelated to you. At least two of these three letters must be from adults who are notemployed at Amery High School; one letter may be from an Amery High School employee if you wish. Committee members will not be able to write letters of recommendation.
Committee Members: Mr. Doerfler, Mrs. Coleman, Mrs. Ganje, Mrs. Kurtzhals,
Mrs. Moreau, Mrs. Lockwood, Mr. Melberg, and Mrs. Rimestad
3.)A typed, double-spaced essay of no more than one page, addressing the following items:
Describe any prior experiences you have had which demonstrate your service to others. In addition, describe how these experiences have shaped/influenced you and your life as well as why you think service to others is important.
Please type or print all answers neatly in black ink.
Student’s name: First ______Last ______
Gender F M Birthdate ______/______/______
month day year
Address______
City______State ______Zip______
Phone (_____)______E-mail ______
Mother’s name and information:
First______Last ______
Address (if different from above) ______
Work Phone (______) ______Employer ______
Occupation ______
Father’s name and information:
First ______Last ______
Address (if different from above) ______
Work Phone (______) ______Employer ______
Occupation ______
Emergency contact (if parents are unavailable):
First ______Last ______
Phone (______) ______
Relationship ______
Health: Do you have any allergies? Yes No
Please list any allergies: ______
Can the allergy be controlled with medicine? Yes No
If no, a doctor’s statement will be required.
Would you be taking any medication(s) during your trip? Yes No
If yes, what kind and for what reason(s)?
______
Are there any other health concerns we should know?
______
Note: Medication, allergies, dietary needs must be managed by the student and must not require any special attention.
About you: Describe your interests (music, sports, or other activities; favorite school subjects; future plans):
______
______
______
______
______
Describe your character and personality. What traits do you possess that would make you a good candidate for this program?
______
______
______
______
______
What languages, if any, have you studied? (Check all those that apply.)
SpanishLevelscompleted ______
FrenchLevels completed ______
Other ______Levels completed ______
What travel experiences, if any, have you had?
Within the United States: ______
______
______
______
______
Outside the United States: ______
______
______
______
______
By my signature below, I certify that I have read this document and all other information regarding this program and that I agree to the conditions for my child’s participation. I further certify that no information regarding this participant’s health or behavior has been omitted or misrepresented. I grant permission for my child to participate.
______
Parent signature Date
By my signature below, I certify that I have read the information regarding this program and agree to the conditions for participation.
______
Student signature Date