YR Alumni Network, Inc

YR Alumni Network, Inc.

1101 30th Street, N.W., Suite 500

Washington, D.C. 20007

Website:

RETURN TO E-Mail:

2016 Scholarship & Training Grant Application

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PART I: APPLICATION FOR

First-Time YRLC Attendees only:

Chairman’s Scholarship (named for deceased YRNF Chairs)

Advanced Leadership Scholarships honoring: (open to all):

F. Clifton White Lee Atwater Audrey Merkin Kathryn Royce Coombs State-specific scholarship for the State of ______

Other Training Grant (specified below)

To Attend:

YR Leadership Conference. Federalist Society Conference

Leadership Institute Training Fund for America’s Studies School

Other Training; Specify:

Date(s) of Training: ______

PART II: NAME AND CONTACT INFORMATION

(A) Applicant’s Name in full:

______

Family Name (Last Name) First, Middle, and Other Names

Title: Mr. Ms. Mrs.

(B) Address to which all correspondence (including admission decision) should be sent:

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cell Telephone Number

E-Mail Address:

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

Street Address

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cell Telephone Number

(D) Emergency Contact:______

Name

Relationship:______

Street Address

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cell Telephone Number

(E) Country of CitizenshipCountry of Birth:

(F) If not U.S. Citizen, Visa or Permanent resident number

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(G) How did you hear about the YR Alumni Network’s scholarship program? (please check all that apply)

Poster Advertisement Professor
Mailer/Flyer C-SPAN YR Club YRNF Website

YR Alum/Friend (Please Enter Name of Contact) Walk-In
Other (Please Specify)

Under Title VI of the Civil Rights Act of 1964, the YR Alumni Network we may be required to ask the following question of U.S. citizens and permanent residents. Answers will not affect our admissions decisions. Your cooperation is requested and appreciated.

How do you describe yourself? (optional)

African-American Asian or Pacific Islander
Hispanic/Latino White, Non-Hispanic
Native American (American Indian, Alaska Native, Native Hawaiian)
Other (Please Specify)

NOTE: THIS PAGE WILL BE WITHHELD FROM THE PANEL SELECTING SCHOLARSHIP RECIPIENTS AND IS FOR OUR FILES ONLY TO BE USED FOR STATISTICAL ANALYSIS AND FOR PERMANENT RECORDS REQUIRED BY LAW.

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

PART III: QUALIFICATIONS OF APPLICANTS

(D) Education:

1. ______

Name of Institution City/Town State/Province Country

______

Dates Attended (Month and Year)Field of StudySpecify Degree or Certificate Received or Expected

2. ______

Name of Institution City/Town State/Province Country

______

Dates Attended (Month and Year)Field of StudySpecify Degree or Certificate Received or Expected

High (Secondary) School Dates AttendedDiploma or equivalent

From To Yes No

______

(E) Full-Time Employment History

(List current or most recent first)

Name of EmployerJob title or type of workDates worked (month and year)

From To

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(F) Honors and Awards: List academic and/or professional honors, including scholarships, prizes, awards, etc, and dates received.

______

(G) Arts and Culture: List any training you have received in the fine arts (including music and dance) and any instrument you play and/or your proficiency in any of the fine arts.

______

(H) Sports and Athletics: List any training you have received in the sports and athletics including any team sports you have played in school or regularly participate in.

______

(I) Have You Attached a Current Resume: Yes No

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(I) Life and Career Goals: Please articulate your Life and Career Goals and how the scholarship or grant you are applying for may contribute to your attainment of these goals in 250 words or less (You are encouraged to type your response on a separate page):

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(J) Essay: (Pick one of two options) Please complete the following essay in 500 words or less (You are encouraged to type your response on a separate page):

1. Describe your earliest memory of politics. What lessons and motivations do you associate with that memory?

2. Describe a politician you admire and why.

Please Indicate whether you are responding to Item (J)1 or (J)2

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

PART IV: DEMONSTRATED INTERESTS

The following information is only considered if your application is considered to have met the minimum qualifications for a YR Alumni Network Scholarship or Training Grant and may be used both to choose between equally-qualified applicants and/or to assign to a specific scholarship or grant that incorporates one of the below characteristics as a criteria.

(A) Charitable Activity: List any charitable organizations and drives in which you participated, your role or activity, and the date(s) in which you participated.

______

(B) Community/Civic Activity: List any non-partisan civic activities and organizations (examples: PTA, Little League, Scouting, Jaycees, Rotary, etc.) in which you participated, your role or activity, and the date(s) in which you participated.

______

(C) Political Activity: List any political party or election-related activities and organizations (in which you participated, your role or activity, and the date(s) in which you participated

______

(D) Club Leadership: List any activities or accomplishments of your local club in which you played a substantial role, and the date(s) in which you played this role.

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(E) Informational Sources: Please list all newspapers, magazines, websites, that you regularly browse or subscribe to.

______

(F) Reading Choices: Please list the last three books (other than textbooks assigned to you by an educational institution) that you have read.

______

(G) Entertainment Choices:

1. Please list any television programs that you regularly (weekly) watch.

______

Please list the last movies (films) (other than textbooks assigned to you by an educational institution) that you have read.

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

(H) International Experience. Please list all countries in which you have lived or studied for more than one month after the age of 10. Include any countries in which you plan to live or study after application but before the 2016-17 study year. Information not included in this section that is discovered later could disqualify a candidate.

______

(I) Language(s) Spoken. Please list all language(s) you speak , read, or have studied, and describe your fluency.

______

(J) Previous Leadership Training Conferences or Conventions. Please list all leadership training conferences and/or conventions you have attended. (Note: Some conferences may disqualify you for certain scholarships/grants but may also commend you for others. Please see instructions for clarification.)

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

PART IV: ADDITIONAL FINANCIAL ASSISTANCE

(I) If you are attending a conference which requires you to travel, do you intend to obtain your own housing or will you require assistance?

(II) If yes, please list potential donors or sponsors who may assist you in funding travel and housing expenses. (Note: This information is only requested to assist you in identifying potential sponsors and will not be used to solicit contributions unless you are chosen.).

1.NameReason/Relationship

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cell Telephone Number

2.NameReason/Relationship

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cell Telephone Number

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

NOTE: Portions of the information provided in this application may be shared with or referred to other 501(c)(3) organizations which provide scholarships and/or make tuition grants in order to provide you an additional opportunity for study. If you do not wish to have your information shared with such organizations, please so indicate below.

Please share my information with other 501(c)(3) organizations which provide scholarships and/or make tuition grants in order to provide me with an additional opportunity for study.

Please do not share my information with any other organization.

______

SignatureDate

YR Alumni Network, Inc.

1101 30th Street, N.W., Suite 500

Washington, D.C. 20007

Website:

RETURN TO E-Mail:

RECOMMENDATION FORM for All Scholarship Applicants

SECTION 1 – To be completed by the applicant

Name of applicant:

Club/sponsor name and address:

I, waive do not waive my right to access information on the Recommendation Form.

APPLICANT’S SIGNATUREDate

SECTION II -- To be completed by an academic instructor or employer/supervisors.

In what capacity and how long have you known the applicant?

______

How firm is the applicant’s commitment to his/her proposed field of study?

______

In what way would further study contribute to the applicant’s academic or professional development?

______

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

4. How would you rate the applicant in the following areas? If you are able to evaluate an area, please leave it blank.

Excellent Very Good Average Below Average Unable to Evaluate

Leadership

Initiative

Seriousness of Purpose

Enthusiasm

Adaptability

Maturity

Emotional stability

Public speaking

Community service

5.Please cite specific examples of how the applicant has demonstrated the qualities listed in question 4.

______

6. Additional comments:

______

Name______Title or Position______

Signature______Date______

Institution______

Telephone______Fax______E-mail______

YR Alumni Network, Inc.

1101 30th Street, N.W., Suite 500

Washington, D.C. 20007

Website:

RETURN TO E-Mail:

CLUB ENDORSEMENT for All Scholarship Applicants

The YR-AN Affiliate or YR Club of ________

NAME

______

CITYSTATE/PROVICECOUNTRY

after consideration of ______applicants for ______available scholarships, proposes ______for a YR Alumni Network scholarship and forwards this application to the appropriate Region/State/District official, as instructed.

The YR club selection committee

______Did ______did not interview this candidate

Each recipient of a YR Alumni Network Scholarship is assigned a sponsor/counselor. The sponsor/counselor is a knowledgeable YR Alumni who serves as a resource and mentor to the scholar, before, during, and after the scholarship period.

The club president recommends the following YR Alumni as a sponsor/counselor, should the applicant receive a scholarship:

Sponsor/Counselor:______

Name

Address:

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number Cell Telephone Number

E-Mail Address:

Applicant’s Name:______

Family Name (Last Name) First, Middle, and Other Names

NOTE: If no sponsor/counselor is listed, the club president will be designated as the scholar’s sponsor/counselor.

______

NAME OF CLUB PRESIDENT (PLEASE PRINT)

SIGNATURE OF CLUB PRESIDENTDATE

Address:

Number and Street

CityState Zip (Postal) Code Country

Office Telephone Number Fax Number Home Telephone Number

Cellular Telephone Number

E-Mail Address:

The sponsor club president is requested to make a complete photocopy of this application for club records before forwarding the application to the YR Alumni Network, Inc.