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If you are already in at least your second year of tertiary education, can show a history of goalsetting and goals achievement, while contributing service to others (individuals, groups or the community at large) and doing so while having to overcome significant barriers we urge you to apply for a Goal Setter Award 2016
Two or more award winners will personally receive their awards at a celebration dinner and award presentation function at the
InterContinental Hotel, Wellington 26 th February 2016.
by 4 Dec 2015
Application forms are available from our web site: http://www.port-nicholson-rotary.wellington.net.nz or from your Course Information Centre, which provide details for the submission of completed applications.
Applications close Friday 4th December 2015.
Eligible students are those who at the time of application are undertaking tertiary study in the Wellington / Kapiti areas, towards completion of an undergraduate or post-graduate degree, a National Certificate, or structured workplace learning for completing a Modern Apprenticeship.
Please do not apply if your course of tertiary study only started in 2015 or has yet to start.
Selection is based on written submissions and an interview process.
Interviews will be held in Wellington in February 2016. There is no age limit for applicants. You must be available in person for an interview and to attend the celebration dinner.

Please complete this application on line and email it to the Rotary Club of Port Nicholson Inc, c/ o Jeff Lee at leehouse@xtra.co.nz
as soon as possible but no later than Friday 4 th December 2015 as an attachment to a message entitled Goal Setter Awards.
Please note:

Do not send anything by ordinary mail.
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Provide the information per the headings below.

You should, at the time of making this application, be in at least your second year of tertiary education.

Do not apply if your tertiary study only started in 2015 or has yet to start.
1.
Surname/Family Name: Click here to enter text.
2.
Given Names: Click here to enter text.
3.
Birth Date: Click here to enter a date.
4.
Current address: Click here to enter text.
5.
Expected address in Jan/Feb/March 2016 or home address if different from item 4 above: Click here to enter text.
6.
Phone contact: Click here to enter text.
7.
Name your Programme of Study and Training Organisation or Tertiary Institution during
2015: Click here to enter text.
8.
The length of the Programme is: Click here to enter text.
9.
Programme start date was: Click here to enter a date.
10.
Expected programme completion date is: Click here to enter a date.

11.
What goals have you set and what have you achieved in your tertiary study so far ?
(state year, subjects, credits, grades):
Click here to enter text.
12.
Give details of any previous training organisations or tertiary institutions you have attended, and years of attendance:
Click here to enter text.
13.
What secondary school did you attend?
Click here to enter text.
14.
List any awards won or scholarships achieved.
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15.
What contribution have you made or are currently making to serve others – individuals, groups or the community at large? (Max. 200 words)
Click here to enter text.
16.
Significant challenges: List significant challenges that you have faced and actions taken to overcome them relevant to the goals you have set for yourself to date relevant to your: (Max.
300 words)
16.1.
Study programmes:
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16.2.
Career:
Click here to enter text.
16.3.
Personal challenges (health, family circumstances, accidents etc):
Click here to enter text.
17.
Plans for the future: What plans you have made towards the achievement of your goals relevant to: (Max 300 words)
17.1.
Study programmes:
Click here to enter text.
17.2.
Career:
Click here to enter text.
17.3.
Personal challenges:
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18.
19.
How does your goal-setter target setting, education achievements to date, service to others and challenges overcome make you a top-flight candidate? (Max. 200 words)
Click here to enter text.
20.
Future Vision: Explain how you would use the award, if you were successful, towards achieving your goals and / or future plans: (Max 200 words)
Click here to enter text.
1.
By e-mailing this information I confirm that all information included in this application is true and correct and I agree that relevant information about me, held by my Programme or Training
Leader, can be used to support this application.
Click here to enter text.
Click here to enter a date.
(Signature-Name & Date of completed application e-mailed )
N.B. Selected finalists will need to be available to attend interviews to be held in Wellington in February
2016 and award winners will need to be personally present to receive their awards at the Rotary Club of
Port Nicholson Goal Setter presentation function to be held in Wellington 26 th February 2016.
Selected finalists may be asked to furnish the name of a person willing and able to provide a reference which incorporates conformation of the finalist’s study programme and exam successes to date.