APPLICATION FORM

All information must be typed – handwritten applications will not be accepted.

This form must be MAILED with the accompanying documents – faxes and e-mails will NOT be accepted

Please read the Additional Information on page 8

Type your answers into the space provided

Please do not use abbreviations when referring to organizations you have volunteered with or worked for

Send Completed Application Packages To: Terry Fox Humanitarian Award Program

AQ 5003, Simon Fraser University

Burnaby BC V5A 1S6

GENERAL INFORMATION

Tel: (778) 782-3057

SURNAME:GIVEN NAME(S): Male Female

PERMANENT MAILING ADDRESS (Please include postal code):

TELEPHONE NO. (Please include area code):

E-MAIL ADDRESS:

*You will receive email confirmation that your application was received.

DATE OF BIRTH: PLACE OF BIRTH: Canadian Citizen

Landed Immigrant

Other

NAME AND ADDRESS OF PARENT(S), GUARDIAN(S) OR NEXT OF KIN (Please include postal code):

EDUCATION BACKGROUND

Presently attending SECONDARY SCHOOL COLLEGE / CÉGEP UNIVERSITY

NAME AND ADDRESS OF INSTITUTION CURRENTLY ATTENDING (Please include postal code):

TELEPHONE NO. (Please include area code): CURRENT GRADE OR LEVEL:

*Note: You must include an official transcript of the past two years of schooling with your application*

EDUCATION PLAN FOR NEXT YEAR: COLLEGE / CÉGEP UNIVERSITY GRADE OR LEVEL:

NAME AND LOCATION OF INSTITUTION WHICH YOU PLAN TO ATTEND NEXT SCHOOL YEAR:

FIELD OF STUDY:

WORK EXPERIENCE (Including Permanent or Part-Time Positions)
Employer’s Name & Address / Dates of Employment / Position(s) Held
1.
2.
3.
4.
REFERENCES

Please list the names, addresses, telephone numbers and occupations of three people who have completed Referee Forms on your behalf. Candidates should ensure the referees are aware of the nature of the Terry Fox

Humanitarian Award Program when they complete the forms.Referees can not be relatives of the applicant.

*Note: It is the candidate’s responsibility to ensure the letters of reference are in sealed envelopes and accompany the application package.

*Please do not supply more than three Referee Forms – additional references will not be considered.

REFEREE #1:

Name: Occupation:

Complete Mailing Address (and postal code):

Telephone (include area code and extensions)Day: Evening:

Relationship to you: How long have you known this person?

REFEREE #2:

Name: Occupation:

Complete Mailing Address (and postal code):

Telephone (include area code and extensions)Day: Evening:

Relationship to you: How long have you known this person?

REFEREE #3:

Name: Occupation:

Complete Mailing Address (and postal code):

Telephone (include area code and extensions)Day: Evening:

Relationship to you: How long have you known this person?

PERSONAL BACKGROUND

Candidates are evaluated as to how they reflect the highest ideals and qualities of citizenship and

Humanitarian service while in pursuit of their academic, extra-curricular, amateur sport, fitness, health and voluntary community service endeavours.

You are required to provide information in these areas.

1.a) Please describe what voluntary humanitarian deeds (helping others) you have performed in your community. (Please indicate the date(s) and the approximate number of hours. Specify if the hours are per week, per month or for a one time event)

Organization and/or description of position held: / Date(s) (from – to): / # of hours:

1.b) Please describe what voluntary humanitarian deeds (helping others) you have performed at your school. (Please indicate the date(s) and the approximate number of hours. Specify if the hours are per week, per month or for a one time event)

Organization and/or description of position held: / Date(s) (from – to): / # of hours:

2. Which of your experiences in voluntary community service have you found to be the most satisfying and why? (Please limit your answer to 200 words)

  1. What influence do you think your experience with voluntary community service will have on your intended vocation? (Please limit your answer to 200 words)
  1. STUDENT ACTIVITIES – Please list the type of activities you have participated in at school, including offices held. Do not include the humanitarian deeds listed in 1b. Please indicate dates and duration of participation.
  1. AWARDS AND RECOGNITION – Please list scholarships, prizes and other awards. Please indicate dates and amounts if applicable.

ACADEMIC –

ATHLETIC –

OTHER –

  1. ATHLETIC BACKGROUND – Please list your athletic activities and best personal accomplishments in team or individual sports (maximum of five) within the last five years. Please indicate the date, the sport or event, your involvement and your results.

1.

2.

3.

4.

5.

  1. What benefits do you feel you have derived from your participation in organized amateur athletics or your personal fitness program? (Please limit your answer to 200 words).
VERIFICATION

I hereby certify that the above information (questions 1 through 7) is accurate.

Signature of Principal, Guidance Counsellor or Referee

  1. What particular personal obstacles have you been required to overcome while in pursuit of your academic, extra-curricular, amateur sport, fitness, health and voluntary community service endeavours? (Please do not exceed 500 words)
VERIFICATION

Signature of ApplicantDate

I hereby certify that the above information is correct and can be verified on request.

Have you included:

Official Transcripts of the last two years of schooling (in sealed envelopes)?

Three Referee Forms (in sealed envelopes)?

Your email address to receive confirmation?

Note: Application forms, official transcripts and supporting documents become the property of the Terry Fox Humanitarian Award Program and will not be returned. Please make a copy of your application package before you send it to us.*

Name, address and telephone number of the school or institution the applicant is currently attending:

Name:

Address (including postal code):

Telephone No. (including area code and extensions):

ADDITIONAL INFORMATION

APPLICATION
  • Information supplied for each question must not exceed the allotted space.
  • You may photocopy this application if further copies are required.
  • The deadline for submissions is February 1st (post-marked) of each year. No applications post-marked after this date will be accepted.
  • Application material will not be returned under any circumstances, nor will it be used for subsequent years.
  • In order to receive acknowledgement of receipt of your application, the applicant must include their email address.
SELECTION
  • A preliminary review of applicants will be made on the basis of submitted material.
  • A Provincial Interview Committee will then invite those applicants who are deemed suitable to a personal interview. All transportation and supplementary costs of attending the interview are the responsibility of the applicant. The date given for the interview is not negotiable. If you are unable to attend the interview then you will not be eligible to receive the award.
  • The results of the interviews will be forwarded to the Program’s Selection Committee of the Board of Directors for their consideration. Thank you to all those who apply however due to the increasingly large volume of applications we receive, only those selected to take part in the interview process will be contacted.
  • The decisions of the Board of Directors are final and are considered binding.
VALUE OF THE AWARD
  • The Terry Fox Humanitarian Award is $7,000 annually, or $3,500 annually for students who do not pay tuition fees. The award is tenable for a maximum of four years (sooner if a first degree is obtained).
OTHER INFORMATION
  • The Terry Fox Humanitarian Award is only tenable at Canadian institutions.
  • If a Terry Fox Humanitarian Award recipient receives other awards and declines to accept the Terry Fox Humanitarian Award, s/he may return the Award to the Program. S/he would still be considered a Terry Fox Scholar and would maintain the prestige of having been granted the