Candidate Control Form

CANDIDATE CONTROL FORM Please type or print, using black or blue ink. STATE OF LEGAL RESIDENCE

1. Legal name Title First Middle Name/Initial Last Suffix

Permanent address 1 Permanent address 2

City State/Province ZIP/Postal Code Country

2. Gender Male Female

3. Do you attend school in a state or country other than your state of legal residence, such as a boarding school? If yes, 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 yes, 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 507.931.8345 or email PSP@scholarshipamerica.org before continuing. This may affect your status as a candidate for the program.

5. Telephone ( ) - Foreign phone

6. DOB

/ /

Age

7. Contact information where you can be reached until September 30, if different from those provided above: Mailing address 1

Mailing address 2

City State/Province ZIP/Postal Code Country

Telephone ( ) - Foreign phone

8. E-mail

9. High school High school address 1

High school address 2

City State/Province ZIP/Postal Code Country

10. 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 Middle Name/Initial Last Suffix

11. 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 Name/Initial Last Suffix

12. 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. You must include either the teacher’s school address or personal address below.

Teacher name Title First Middle Name/Initial Last Suffix

Teacher school name Teacher school address 1

Teacher school address 2

City State/Province ZIP/Postal Code Country

Teacher’s primary subject area Teacher home address 1

Teacher home address 2

City State/Province ZIP/Postal Code Country

OMB No. 1860-0504 – Approved for use through 7/31/21

SUPPORTING INFORMATION FOR THE 2020 U.S. 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.

In the event that you are chosen as a Presidential Scholar would you like to share your email address with the Presidential Scholars (Alumni) Association to be informed of future opportunities and to

be connected with Scholars from the past? Yes No

AFFIRMATION OF CANDIDACY

AND AUTHORIZATION FOR RELEASE OF INFORMATION

I, (Full name) , 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. I am a U.S. citizen or permanent legal resident. 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 U.S 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 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 U.S. Presidential Scholars Program.

Student’s signature Date

Parent’s or guardian’s signature Date

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.

1. Biographical Information

Gender: Male Female

Legal name: First MiddleName/Initial Last Suffix

Permanent home address: Street City State/Province Zip/Postal Code Country

Telephone ( ) -

DOB

/ /

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 U.S. Presidential Scholars Program,

U.S. Department of Education, 400 Maryland Avenue SW, Washington, D.C. 20202-8173.

2. Education

   1. Name of high school currently attending City State/Country ZIP/Postal Code

SAT: Evidence-based Reading and Writing plus Math score. Enter Sum of Scores. Not to exceed 1600 Test Date

ACT: English, Reading, and Math. Do not include Writing or Science Reasoning. Enter sum of scores. Not to exceed 144 Test Date

2. 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
1.
2.

3. 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
1.
2.

4. Name of first-choice college or university City State/Country

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

6. Do you plan to go to graduate or professional school? Yes No

7. Have you made any career decisions? Yes No

If yes, specify:

3. Activities and Work Experiences

   1. 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
1.
2.
3.
4.
5.
6.
7.
8.

Name (Print/Type)

OMB No. 1860-0504

Approved for use through 7/31/21

2. 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
1.
2.
3.
4.
5.
6.
7.
8.

3. 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
1.
2.
3.
4.
5.
6.
7.
8.

4. List jobs you have held in the past three or four years. Use separate lines for summer and school year employment.

	Job and type of work	Employer	Sum- mer	School year	Approximate dates of employment	Approximate number of hours per week
1.
2.
3.
4.
5.
6.
7.
8.

Name (Print/Type)

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.

4. Candidate’s Self Assessment

   1. Describe any characteristics of your family or your community that have been important to your personal development.

2. Respond to one of the following short essay questions. Choose Option A or B.

1. 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.

2. If you could improve one thing in the world, what would it be?  Why would you change it? How would you change/improve it?

Name (Print/Type)

1. 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?

2. 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?

Name (Print/Type)

3. Name the teacher or instructor who has influenced you most significantly during your school years and whom you would like honored. Please be sure to print or type the teacher’s name clearly.)

Teacher name: Title First Middle Name/Initial Last Suffix

Teacher’s school:

Name

City State/Province ZIP/Postal 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, that you are a

U.S. citizen or permanent legal U.S. resident, and that you have read the “Important Submission Requirements” document posted on the U.S. Presidential Scholars Program website with the downloadable application materials.

Date Signature

This form must be returned to:

U.S. Presidential Scholars Program One Scholarship Way

Saint Peter, MN 56082 507.931.8345

and RECEIVED no later than February 25, 2020

Name (Print/Type)

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 side 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.

U.S. 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.

Please check one:

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Check the box next to the race(s) 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.

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.

Do you consider yourself to be physically challenged or disabled? Yes No

If so, please briefly describe your disability:

Name (Print/Type)