Helene D. Stoneman Scholarship
and Civic Leadership Program
2015 Application Form
Applications are due Monday November 23, 2015
To be filled out by the applicant and the recommending YouthBuild staff person
PERSONAL INFORMATION - Please provide us with your current contact information.
Last Name: ________________________
First Name: _________________
Middle Initial: _______
Address: ________________________________________
City: _____________________________
State: ____
Phone: (_____) ____________________
Email: ____________________________________________
Gender (optional): ___ Female
Race (optional):
___ Male
ZIP: _______
Age (optional): ______
___ African American
___ Asian American
___ Native American
___ White
___ Hispanic
___ Multi-Racial
___ Other
YOUTHBUILD PROGRAM STUDENT DATA
Please include a copy of an official high school diploma or its equivalent.
Graduation Date
Month ____ Year ______
Date Received DIPLOMA or its Equivalent
Month ____ Year ______
GED score (if applicable) __________
Community College Admission Test Score __________ or SAT/ACT Score __________
UNDERGRADUATE AND GRADUATE STUDENT DATA
To be completed by applicants currently in college or graduate study.
Name of College You Attend: ___________________________________________________________
City: _______________________________
State: ____
___ 2-year Community or Junior College
___ 4-year College or University
___ Graduate Study
Year in college or graduate school as of September 2015 __ 1 __ 2 __ 3 __ 4 __ 5 __ Graduate Study
2015 Helene D Stoneman Scholarship Application
Major or course of study: _____________________________________
Current college cumulative grade point average (4.0 Scale): ________
Please include a copy of your college’s official transcript.
Expected date of graduation: ____ Month
_____ Year
Degrees Completed
___ Associate’s
___ Bachelor’s
Date degree received: ____ Month
___ Master’s
___ Doctor’s
___________________ Other
_____ Year
To be completed by applicants who are entering or changing college.
Name of College You Plan To Attend:
____________________________________________
City: _______________________________
State: ____
___ 2-year Community or Junior College
___ 4-year College or University
___ Graduate Study
Year in college or graduate school as of September 2015 __ 1 __ 2 __ 3 __ 4 __ 5 __ Graduate Study
Major or course of study: _____________________________________
Current college cumulative grade point average (4.0 Scale): ________
Please include a copy of your college’s official transcript.
Date of graduation:
Degrees sought:
___ Associate’s
____ Month
___ Bachelor’s
_____ Year
___ Master’s
___ Doctor’s
___ Master’s
___ Doctor’s
___________________ Other
Degrees Completed
___ Associate’s
___ Bachelor’s
Date degree received: ____ Month
___________________ Other
_____ Year
FINANCIAL INFORMATION
Your Financial Resources
Scholarships
Describe
$_________ ____________________________________________________
Grants
$_________ ____________________________________________________
Segal AmeriCorps Ed. Award
$_________ ____________________________________________________
IDA
$_________ ____________________________________________________
2015 Helene D Stoneman Scholarship Application
Educational Loans
$_________ ____________________________________________________
Personal Savings
$_________ ____________________________________________________
Family Contributions
$_________ ____________________________________________________
Other Resources
$_________ ____________________________________________________
Total Financial Resources
$____________
Your College Expenses
Tuition ………………………….
$__________
Room & Board ……………….
$__________
Other Expenses ……….........
$__________ Describe: _________________________________________
Total College Expenses …….
$____________
Your Employment
Are you working or planning to work while going to school? ____ YES
If YES, please check one:
____ part-time
____ full-time
Employer:
___________________________________________
Job Description:
___________________________________________
____ NO
___________________________________________
Monthly Wages:
$ _____________
CIVIC ENGAGEMENT ACTIVITIES
Are you or have you ever been involved in any of these civic engagement activities?
(Please check all that apply)
___ Voter Registration ___ Political Campaign Work ___ Meeting with Elected Officials ___ Political Rallies
___ Other Political Activities
___ Non-YouthBuild Political Activities
Name of Organization
City
State
___ Other
Activities
____________________________
__________________ _____
________________________________
____________________________
__________________ _____
________________________________
2015 Helene D Stoneman Scholarship Application
____________________________
__________________ _____
________________________________
____________________________
__________________ _____
________________________________
Are you registered to vote? ____ YES ____ NO
LEADERSHIP AND COMMUNITY SERVICE ACTIVITIES
Are you or have you ever been engaged in any of these leadership positions?
(Please check all that apply)
___ YouthBuild Program Policy Committee
___ Young Leaders Council
___ National Alumni Council
___ YouthBuild Program Board of Directors ___ YouthBuild USA Board of Directors
___ AmeriCorps Education Award
___ VOICES Advisory Council
___Other YouthBuild Leadership Positions
___ Other Organizations
Name of Organization
City
State
Activities
____________________________
__________________ _____
________________________________
____________________________
__________________ _____
________________________________
____________________________
__________________ _____
________________________________
____________________________
__________________ _____
________________________________
Have you ever attended any of the following leadership events?
(Please check all that apply)
___ National YouthBuild Conference of Young Leaders
___ Regional YouthBuild Youth Conference
___ Other YouthBuild Events
___ Non-YouthBuild Leadership Events
___ Alumni Xchange
Please Describe: ____________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please describe any other community or volunteer activities you have participated in during the past four
years, including year(s) and length of service. Indicate any special awards or honors you have received:
Name of Organization: __________________________________
City, State: _______________________
Activities: __________________________________________________________________________________
___________________________________________________________________________________________
Name of Organization: __________________________________
2015 Helene D Stoneman Scholarship Application
City, State: _______________________
Activities: __________________________________________________________________________________
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Name of Organization: __________________________________
City, State: _______________________
Activities: __________________________________________________________________________________
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Name of Organization: __________________________________
City, State: _______________________
Activities: __________________________________________________________________________________
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Name of Organization: __________________________________
City, State: _______________________
Activities: __________________________________________________________________________________
___________________________________________________________________________________________
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Name of Organization: __________________________________
City, State: _______________________
Activities: __________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
GOALS AND ASPIRATIONS
Write a brief essay (200-300 words) on your goals as they relate to your education, career, future leadership
roles, and other future plans. Use additional sheets if necessary.
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2015 Helene D Stoneman Scholarship Application
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YOUTHBUILD PROGRAM STAFF RECOMMENDATION
Please describe the reasons why this applicant should receive a Helene D. Stoneman Scholarship and
Civic Leadership Program Award. Also indicate why this YouthBuild graduate is likely to succeed in
college.
Applicant’s Name: ___________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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2015 Helene D Stoneman Scholarship Application
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Recommending YouthBuild Staff Signature: ______________________________________ Date: ________
APPLICATION CHECKLIST
This scholarship application form becomes complete only if you have enclosed the following materials:
We encourage you to submit any and all documents via email, if possible.
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Scholarship Application Form
Essay on Goals and Aspirations (200-300 words)
YouthBuild Program Staff Recommendation
Application Checklist, including signatures
Official copy of GED or High School Diploma
Official copy of GED score
Official copies of all college transcripts of grades (For nominees who are current or previously
enrolled in college)
ALL application materials are due Monday
2015 Helene D Stoneman Scholarship Application
November 23, 2015
EMAIL:
Charles Clark, cclark@youthbuild.org
MAIL:
YouthBuild USA
Attn: Charles Clark
Vice President for Asset Development
58 Day Street
Somerville, MA 02144
TEL:
FAX:
Charles Clark, 617-741-1288
Charles Clark, 617-623-4359
CERTIFICATION
I certify that the information provided is complete and accurate to the best of my knowledge.
Applicant’s Signature _________________________________________________
DATE __________
Recommending YouthBuild Staff Signature _______________________________
DATE __________
Recommending YouthBuild Staff Name
_______________________________
Title ____________________________ YouthBuild ____________________________________________
2015 Helene D Stoneman Scholarship Application
YouthBuild USA
Information Practices Disclosure Statement
This Disclosures Statement summarizes the practices of YouthBuild USA (hereinafter, “YouthBuild”) with respect to the
collection, use and disclosure of personal and financial information regarding Applicants and Participants in the Helene D.
Stoneman Scholarship and Civic Leadership Program (“Program”).
Collection of Applicant/Participant Information
YouthBuild solicits and receives information regarding Applicants and Participants in the Program (“Applicant/Participant
Information”) from the following sources: The Applicant or Participant, the applicant’s local YouthBuild program, the
sponsoring organization of theYouthBuild program, educational institutions, and third party references provided by the
Applicant or Participant. In addition, YouthBuild may obtain information regarding Applicants or Participants from credit or
police reports requested by YouthBuild. Finally, YouthBuild may receive unsolicited Applicant/Participant Information
provided to YouthBuild by others.
Use of Applicant/Participant Information
YouthBuild may use Applicant/Participant Information to evaluate and determine eligibility of Applicants to participate in the
Program and of Participants to continue to participate in the Program. In addition, YouthBuild may use Applicant/Participant
Information to assist Applicants/Participants to enroll in and obtain the benefits of the Program. Finally, YouthBuild may use
Applicant/Participant Information to evaluate and improve the Program and to contact Applicants/Participants in the future in
connection with evaluations of or changes in the Program, solicitation of comments and suggestions regarding the Program,
and solicitation of additional Applicants and Participants for the Program.
Disclosure of Applicant/Participant Information
YouthBuild discloses Applicant/Participant Information to the applicant’s local YouthBuild program staff or sponsoring
organization staff. In addition, YouthBuild discloses Applicant/Participant Information to state and federal governmental
authorities and third parties in response to and as directed by judicial order subpoena, or other legal process. YouthBuild
retains a record indicating for each instance to whom and when and for what purpose it discloses Applicant/Participant
Information and what information is disclosed.
Information Security Policies and Procedures
YouthBuild maintains and from time to time updates and improves, policies and procedures, including physical and electronic
information security mechanisms, to protect Applicant/Participant Information from unauthorized disclosure, use, alteration or
destruction.
Disposal/Destruction of Applicant/Participant Information
YouthBuild retains Applicant/Participant Information for the period in which the individual Applicant/Participant is being
considered for enrollment or is actively participating in the Program and for such further period as may be required by state of
federal law or program grant and other funding sources. Following the conclusion of such retention period, YouthBuild may
destroy and or dispose of the Applicant/Participant Information by shredder, electronic deletion, or other means.
For Information Contact
Persons desiring further information regarding YouthBuild’s Applicant/Participant Information practices may contact the
YouthBuild USA Helene D. Stoneman Scholarship and Civic Leadership Program at 617-623-9900 during regular YouthBuild
USA business hours.
This Statement Has Been Updated Through April 30, 2011.
2015 Helene D Stoneman Scholarship Application