Scholarship Application Test

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General Information
Reference Name 1*
First Last
Reference Email 1*
Name
First Last
- UID*
- Phone
Academics
- Major
- Classification
  Academic classification during the term of your participation
- Expected Graduation Year
- Expected Graduation Term

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Internship Information
Have you completed a qualtrics survey for this internship? If you have not, please complete the survey now: https://iastate.qualtrics.com/jfe/form/SV_aa7nZOqrKqpRPox
Company/School District
Student Teachers don't need to know their district assignment. Enter: N/A.
Job/Intern Title
Year You'll be Interning
Semester You'll be Interning
City of Internship
State of Internship
Internship Start Date
Date Format: MM slash DD slash YYYY
Internship End Date
Date Format: MM slash DD slash YYYY
Is this your only internship during this time period?
- Yes
- No
Have you received this scholarship previously?*
- Yes
- No
Internship Course Number*
Number of Internship Credits
Number of Hours / Week Working in the Internship
Supervisor Name*
First Last
Supervisor Email
Supervisor Phone

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Honors
List any honors received within the last 3 years or current memberships in any honor societies.
Honor
Honor Date Received
Date Format: MM slash DD slash YYYY
Honor Description

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School Activities
List participation in major school-related activities within the past 3 years. (Activities should be post-high school years unless you are a freshman.) Describe offices held, committee contribution, and description of activities done as an individual. (If you are still participating in an activity, type "Current" in the end date field.)
Academic Activity
Academic Activity Description
Academic Activity Start Date
Date Format: MM slash DD slash YYYY
Academic Activity End Date
Date Format: MM slash DD slash YYYY
Estimated Total Hours of Academic Activity
Weekly Hours of Academic Activity

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Community-related activities
List participation in community-related activities (civic, youth, political, religious, Greek, etc.). Describe offices held, committee contribution, and description of activities done as an individual. (If you are still participating in an activity, type "Current" in the end dates field.)
Community Activity
Community Activity Description
Community Activity Start Date
Date Format: MM slash DD slash YYYY
Community Activity End Date
Date Format: MM slash DD slash YYYY
Estimated Total Hours of Community Activity
Weekly Hours of Community Activity

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Work Experiences
Work experience (includes part-time, full-time, internship, and summer work). You may specify internships, which could include student teaching.
Company
Job Title
Type of Work
Job Description
Job Start Date
Date Format: MM slash DD slash YYYY
Job End Date
Date Format: MM slash DD slash YYYY
Estimated Total Hours of Work
Weekly Hours of Work

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Essay
Include information in your essay that explains your career goals and how this internship will help you meet those goals in addition to how this scholarship would help offset your expenses. Kindly limit your essay to no more than 500 words.
Essay

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Media Release
Consent
- Yes
- No
- Conditional
I hereby grant permission for Iowa State University to release my name, classification, major, hometown, employing organization, city and state, semester and the name of the scholarship to the news media and public websites in the event I am offered a scholarship.*
Details
If yes with exceptions, please provide exceptions below (200 characters max):
Preferred Newspaper for News Release
Zip Code of the Newspaper
ZIP / Postal Code

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I understand that by accepting a scholarship I give Iowa State University permission to release my name to the donor(s) or donor designee.
I agree that it is my responsibility to ensure everything is complete and accurate and I am also responsible for ensuring my references are professional in nature and have completed the form. I will contact my references if they have not completed the form.
I verify that all the information I have provided is true and accurate, and I understand my application will be disqualified if found to contain false information.
By submitting this application, I agree to waive privacy rights under the Family Educational Rights and Privacy Act of 1974 (FERPA) so my responses may be reviewed for scholarship eligibility.
I understand the decisions of the College of Human Sciences and its departments are final and all applicants will be notified no later than the first day of the semester.

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General Information