Canadate Control Form

CANDIDATE CONTROL FORM

Please type or print, using black or blue ink.

STATE OF LEGAL RESIDENCE

  

1.

Legal name

     

     

  

     

     

Title First MI Last Suffix

Permanent address 1

     

Permanent address 2

     

City

     

State

  

ZIP Code

     

Province

     

Country

     

Foreign ZIP

     

2. Gender

M F

3. Do you attend school in a state or country other than your state of legal residence? If so, please enter:

State/country of school attendance

     

4. Do you live outside of the 50 United States, District of Columbia, or Puerto Rico?

Yes

No

If so, how long have you lived in this location?

     

If your state of legal residence and permanent address differ, or you answered yes to either 3 or 4, call 319/341-2777 or email PSP@act.org before continuing. This may affect your status as a candidate for the program.

5. Telephone

(     )     -     

Foreign phone

     

6. DOB

   /    /     

Age

  

7. SSN

    -    -     

8. Contact information where you can be reached until June 20, if different from those provided above:

Mailing address 1

     

Mailing address 2

     

City

     

State

  

ZIP Code

     

Province

     

Country

     

Foreign ZIP

     

Phone

(   )     -     

Foreign phone

     

9. E-mail

           

10. High school

     

High school address 1

     

High school address 2

     

City

     

State

  

ZIP Code

     

11. On the line below, print your informal name (including your last name) as you would want it to appear on a name tag. Consider how you would want to be addressed by fellow Presidential Scholars.

     

  

     

     

First MI Last Suffix

12. On the line below, print your name as you would want it to appear on a Presidential Scholar medallion. This information cannot be revised at a later date.

     

     

     

     

First Middle Last Suffix

13. Name the educator who has influenced you most significantly during your school years and whom you would like honored. This information should be the same as that provided on page 6 of your Supporting Information Form.

Teacher name

     

     

  

     

     

Title First MI Last Suffix

Teacher school

     

Teacher school address 1

     

Teacher school address 2

     

City

     

State

  

ZIP Code

     

Teacher’s primary subject area

     

Teacher address 1

     

Teacher address 2

     

City

     

State

  

ZIP Code

     

Province

     

Country

     

Foreign ZIP

     

OMB No. 1860-0504 – Approved for use through 10/31/09

SUPPORTING INFORMATION FOR THE

2010 PRESIDENTIAL SCHOLARS PROGRAM

PRIVACY ACT ADVISORY STATEMENT

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with this request for information. Accordingly, pursuant to the requirements for the Act, please be advised:

1. The authority for the collection of these data is Executive Order 11155.

2. Furnishing the information requested is voluntary.

3. The data will be used for selection of Presidential Scholars, engraving of Scholar medallions, and arranging transportation and accommodations for Scholars.

4. Other routine uses of the data are for preparation of the Presidential Scholars Yearbook, public affairs, and press releases to new media.

5. Failure to complete the form will mean that you cannot be included among those candidates being considered for designation as Presidential Scholar.

AFFIRMATION OF CANDIDACY

AND AUTHORIZATION FOR RELEASE OF INFORMATION

I,	     						,	understand that I am a candidate for the honor of Presidential
Scholar, have read the Privacy Act Advisory Statement, and affirm my wish to be considered. In the event I am named a Presidential Scholar, permission is hereby given for the release of materials submitted by me for the use of the Commission on Presidential Scholars and the Department of Education as may be deemed appropriate for purposes of the Presidential Scholars Program. I further consent to the release of photographs which may be taken of me, by or for the U.S. Department of Education
in connection with the Program. I am (check one) willing lling						unwilling				to appear on radio and/or television if such
arrangements can be made by the U.S. Department of Education in connection with the Presidential Scholars Program.
Date		     	Signature

CANDIDATE’S BIOGRAPHICAL QUESTIONNAIRE

Note: The selection of award recipients will be influenced by the completeness, neatness, and legibility of replies. Please type or print, in black or blue ink. Font size must be 11 points or larger. Confine your answers to the space provided; do not attach additional pages.

A. Biographical Information

M

Legal name in full (Print/Type)

     

     

     

Sex

Last First MI

F

Permanent home address

     

     

  

     

Number and Street City or Town State ZIP Code

Telephone Date of birth Age

       

-

       

-

          

    

-

  

-

    

    

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1860-0504. The time required to complete this information collection is estimated to average 16 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to Presidential Scholars Program, U.S. Department of Education, 400 Maryland Avenue SW, Washington, D.C. 20202-8173. Approved for use through 10/31/09.

B. Education

Name of high school currently attending

     

City

     

State/Country

  

ZIP Code

     

SAT: Verbal/Critical Reading

   

Math

   

Writing

   

Test Date

     

ACT: English

  

Math

  

Reading

  

Science

  

Writing

  

Composite

  

Test Date

     

List any other schools that you attended in the last four years in order of attendance, with the most recent one first.

Name of school

Location (city and state)

Dates of attendance

     

     

     

     

     

     

List any advanced or special program, courses, or summer courses you have taken that would not be listed on your transcript. List the most recent first. Do not list AP or honors courses here; they will appear on your transcript.

Course or program

Name of school

Location (city and state)

Dates of attendance

Hours per week

     

     

     

     

   

     

     

     

     

   

Name of first-choice college or university

     

City

     

State

  

What course of study (major) would you like to pursue in college? (You may indicate more than one or answer “undecided.”)

     

Do you plan to go to graduate or professional school?

   

Have you made any career decisions?

Yes

No

If yes, specify:

     

C. Activities and Work Experiences List activities in which you have participated in your school (such as academics, publications, debating, dramatics, sports, music, art, student government, and clubs). Place an “X” in front of those activities you consider most important. Dates must be in the format MM/DD/YYYY. Estimate dates as best you can.

Activity

Dates of participation

Hours per week

Offices held

Special awards or honors

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

OMB No. 1860-0504 Approved for use through 10/31/09

Name (Print/Type)

     

List any special talents (in areas such as music, the arts, sports, published writing or scientific research) that you pursue outside of school.

Talent or activity

Periods of participation

Special honors, recognition, or awards

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

List community activities in which you have participated without pay (such as hospital volunteer, religious work, drug/teen/homework hotlines, or outreach programs).

Type of work

Name of agency or organization

Dates of participation

Hours per week

Special awards

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

     

     

     

   

     

List jobs you have held in the past three or four years.

Job and type of work

Employer

Check one:

Approximate dates of employment

Approximate number of hours per week

Sum-mer

School year

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

     

     

 

 

     

   

OMB No. 1860-0504 Approved for use through 10/31/09

Note: Please be concise. Limit your responses to the spaces provided. Feel welcome to word-process your responses and then paste them on this form. Font size must be 11 points or larger. Do not attach additional pages.
D. Candidate’s Self Assessment
Describe any characteristics of your family or your community that have been important to your personal development.      
Discuss some creative work that illustrates the way you see the world and the way you see yourself in the world. The work may be a scientific theory, novel, film, poem, song, or other art form.      
OMB No. 1860-0504 Approved for use through 10/31/09
Name (Print/Type)							     
What is the most significant contribution that you feel you have made to your community’s well-being or the well-being of an individual or individuals in your community? Why were you motivated to do this? What effect do you think it has had on that person or the community?      
Describe a mistake you made or a challenge you faced. How did you respond to that mistake or challenge, and what did you learn from your experience?      
OMB No. 1860-0504 Approved for use through 10/31/09
E. Name the teacher or instructor who has influenced you most significantly during your school years and whom you would like honored. (Note: Should you become a Presidential Scholar, the teacher you name will be invited to Washington, D.C., and honored for his or her accomplishments. Please be sure to print or type the teacher’s name clearly.)
Teacher’s name	     		     		     	     
Title (Mr., Ms.) First Middle Initial Last
Teacher’s school		     
Name
		     						  	     
City State ZIP code
Teacher’s primary subject area				     
Explain the reason for your selection.      

Please proofread your responses and review this form to make sure you have answered all questions completely. By signing this document you are certifying that all information contained in your application is accurate and correct, and that you have read the “Important Submission Requirements” document posted on the Presidential Scholars Program website with the downloadable application materials.
Date	     		Signature
This form must be returned to: Presidential Scholars Program / 59 301 ACT Drive, P.O. Box 4030 Iowa City, IA 52243-4030 and RECEIVED no later than February 25, 2010
OMB No. 1860-0504 Approved for use through 10/31/09

CANDIDATE ESSAY

Name	     		State	  
Topic: Please attach a photograph of something that or someone who has great significance to you. Explain that significance. Note: If you are visually impaired, you are not required to attach a photograph. Please write about something that or someone who has great significance to you. Your essay should demonstrate style, depth and breadth of your knowledge, and individuality. Confine your response to the front and back of this page. The photograph must be stapled to this page and must not be larger than 5” x 7”. Photographs will not be returned. Typewritten essays are preferable. Font size must be 11 points or larger. If not typed, please print, using black or blue ink.
     
OMB No. 1860-0504 Approved for use through 10/31/09
     
OMB No. 1860-0504 Approved for use through 10/31/09

PRESIDENTIAL SCHOLARS PROGRAM

VOLUNTARY SURVEY FORM

The following information is requested on a voluntary basis. The information will be used for statistical purposes only and will remain confidential. Check the box(es) next to the race/ethnicity with which you most closely identify. You may choose all that apply.
	American Indian or Alaska Native
	A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
	Asian
	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	Black or African American
	A person having origins in any of the black racial groups of Africa.
	Hispanic or Latino
	A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
	Native Hawaiian or Other Pacific Islander
	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	White
	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
	Yes No
Do you consider yourself to be physically challenged or disabled?
If so, please briefly describe your disability:		     

OMB No. 1860-0504

Approved for use through 10/31/09

2010 PRESIDENTIAL SCHOLARS PROGRAM

SECONDARY SCHOOL REPORT

Legal name of student

     

     

     

Please type or print, using black ink.

Last

First

MI

To comply with the provisions of the Family Educational Rights and Privacy Act of 1974, a school must obtain signed authorization before it can release student information for use in this program. Permission is hereby given to school officials to release the secondary school record and other requested information for the student named above for consideration in this award program.

Student’s signature

Date

     

Parent’s or legal guardian’s signature

Date

     

If you have attended this school for less than two years, you may copy this form and request someone from your former school to also complete a copy for you.

School

     

     

  

     

     

Name City State ZIP Code Telephone

Important Instructions for Evaluator and Principal:

The student named above is a candidate for the honor of Presidential Scholar. Please provide thorough and complete responses to the questions on this form. Incomplete or limited answers will place your student at a disadvantage. If you complete this form by hand, please write legibly using black or blue ink. Do not submit a letter of recommendation as a replacement for this form. All extraneous material, including letters of recommendation, are removed from candidates’ files and will not be included with the application for review. If you submit a letter of recommendation, your student’s application will be reviewed as it stands without the letter of recommendation, placing your student at a disadvantage. If you wish, you may cut/copy and paste your answers to the questions on this form from a letter of recommendation. In order to process this student’s application, we must receive this completed form; a 7-semester secondary school transcript, including grades 9-12 (must be sent in hard copy), SAT/ACT scores and any AP test scores (copies are accepted; need not be official); and a school profile, if available. Both the evaluator and the principal must sign this form on page 4. Seal the signed form, transcript, test scores, and school profile in an envelope. A school official’s signature must appear across the envelope seal for it to be accepted by the Commission. Return the signed envelope to the student for submission with his or her application materials, in time to meet the RECEIPT deadline noted below. If you need assistance with this requirement, call 319/341-2777 8:30 am – 5:00 pm Central Time.

All application materials, including this form and transcripts, must be received by 5:00 p.m. Central Time, February 25, 2010. Any application materials not received by that deadline will render the student’s application ineligible for review, regardless of who sends them.

OMB No. 1860-0504

Approved for use through 10/31/09

* Items A-F are required and must be completed by a school official (Counselor, Principal, etc.).

* A. Name of principal

     

     

     

Last First MI

* B. Are you confident that the student will receive a school diploma during the current academic year?

Yes

No

If no, please explain.

     

* C. Expected date of graduation

     

/

    

Month Year

* D. Student’s class rank

     

Number of students in class

     

School does not rank students.

* E. Student’s grade point average

     

on a

     

point scale, based on

  

semesters.

* F. Number of AP courses your school offers:

   

Number this student will have taken by graduation:

   

AP exams taken and results:

     

Does your school offer IB courses? Yes* No

Does your school offer the IB diploma? Yes* No

* This student is taking IB courses an IB diploma candidate not participating in the IB program

G. Who is evaluating the student on the following pages?

Name

     

Relationship to student

     

e.g., Teacher/Counselor

Length of relationship

     

If teacher, please state subject(s)

     

In items H-O, please be concise. Use examples to support your comments. Limit your response to the space provided.

H. What economic or social conditions characterize your community and most of the parents of the children in your school? (For example, is your community a university town, a mill town, a farming area?)      

I. Considering this student’s interests, work habits, and life goals, what is your assessment of the chances that the student will be motivated to take advantage of the opportunities available in college? Please give reasons for your assessment.      

2 OMB No. 1860-0504 Approved for use through 10/31/09

J. Does your school have a service requirement? Yes No If yes, number of hours and type of service required:

     

This student has exceeded met not met the service requirement.

What special features are part of your school’s curriculum (e.g. AP and honors courses, college study, independent study)? Has the student taken advantage of the most challenging opportunities your school has to offer?      

K. Has this student given any strong evidence of leadership ability? Yes No Please explain the criteria on which you base your judgment and how the student meets those criteria. Include a discussion of the student’s principal strength.      

L. Describe how this student demonstrates strong character (e.g. integrity, independence, loyalty, patriotism, self-discipline, employment responsibilities, willingness to work hard, kindness, commitment to high ideals, and caring for others).      

3 OMB No. 1860-0504 Approved for use through 10/31/09

M. Has the student shown exceptional talent or originality in any specific field such as art, music, science, literature, or mathematics? Yes No Please cite examples.      

N. Is there anything else about this student you feel is important for the Commission to know that is not likely to appear in the student’s application or transcript – additional qualities, anecdotes, circumstances, or background that would give the Commission insight into this individual?      

O. What areas, academic or otherwise, have most challenged this student?      

     

     

DATE

EVALUATOR’S SIGNATURE

TITLE

     

     

DATE

PRINCIPAL’S SIGNATURE

TITLE

After completing this form, attach the candidate’s transcript, test scores, and a copy of your school profile, and seal them all in an envelope. Sign your name across the seal and return the envelope to the student for submission with his/her application materials per the deadline noted on Page 1 of this form. If you need assistance with this requirement, please call 319/341-2777, 8:30 am – 5:00 pm Central Time.

4 OMB 1860-0504 Approved for use through 10/31/09