2015 Coca-Cola MENA Scholarship Program
Application Completion Checklist
(Must be completed in English)
Candidate Name
(Full Name as it appears in
passport)
Name of University
(Currently enrolled in)
Year of Study
Concentration Area of Study
E-Mail Address
Home Address
Age
Gender
City and Country
Occupation
In order for your application to be complete, please make sure you submit:
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Completed Application Checklist Form (this page)
Completed Application (p 2-5)
Completed Additional Information (p 6-12)
Legible electronic copy of the picture/information page of passport
Copy of official transcript (please do not submit original transcripts)
* All applications must be received via e-mail by February 6th, 2015. Any applications
received after this time will not be considered. Please e-mail applications to:
MENAscholarships@coca-cola.com
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
2015 Coca-Cola MENA Scholarship Program
Application Form
NAME: ________________________________________________________________________________________
(First)
(Middle)
(Last name as indicated on passport)
CONTACT INFORMATION
Mailing
Address
(if different from
home address)
Cell
Phone
Work
Phone
Home
Phone
PERSONAL DATA
Gender
Date of Birth
(Month, Day, Year)
Country of permanent
legal residence
Dual Citizenship?
Year of Study (check
one)
Male
Female
Place of Birth
(City, Country
Country of
citizenship
Yes
If yes, indicate
country
No
1st Year
2nd year
3rd Year
** YOU MUST PROVIDE AN ELECTRONIC COPY OF THE PICTURE/INFORMATION PAGE OF PASSPORT.
MILITARY STATUS (Men Only)
Check one
Completed
Exempt
Non-Exempt
Excellent
Good
Fair
Writing proficiency (check one)
Excellent
Good
Fair
Speaking proficiency (check one)
Excellent
Good
Fair
** MILITARY EXEMPT PERMISSION FORMS MUST BE COMPLETED PRIOR TO TRAVEL.
ENGLISH LANGUAGE PROFICIENCY
Number of years of English
Study:
Reading proficiency (check one)
Where Studied:
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
N/A
PREVIOUS ACADEMIC HONORS/SCHOLARSHIPS
Please indicate any scholarship, academic awards, or honors that you have received and the year received:
NON-ACADEMIC/EXTRA-CURRICULAR ACTIVITIES
Please list community service, internships, professional training, jobs, sports, or cultural activities in which you have
participated regularly in the past two years. This includes any service as a team leader, council member, or officer in any
institution or activity.
Institution Name, City, Country
Activity and Your Role
Dates of Participation
MM/YY – MM/YY
From:
To:
From:
To:
From:
To:
TRAVEL EXPERIENCE
Please describe any previous travel or study outside of your home country. (Please be sure to include any travel to the
United States for any reason)
Travel Dates
MM/YY – MM/YY
From:
To:
From:
To:
From:
To:
Travel Purpose
(e.g. vacation, school, etc.)
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
US Government
Program? Y/N
PERSONAL STATEMENT
Please answer the following essay questions in the box below. Feel free to use more space if needed.
SHORT ESSAY #1: Why are you interested in participating in the Global Business Institute-MENA program and what
do you hope to gain from it?
SHORT ESSAY #2: Identify one key challenge facing your country today. What innovative idea would you apply to
solving this problem? Please describe what you would propose, including examples, graphics and data as needed.
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
2015 Coca-Cola MENA Scholarship Program
Faculty Recommendation Form
Thank you for taking the time to complete this recommendation form. This form gives us an idea of the student’s strengths and
weaknesses. Please return this completed form to the student in a sealed envelope with your signature over the seal. He or she will
submit it along with their completed application.
Student Name
Faculty name and email
Faculty Signature
On a scale of 1 to 10 (1 being the lowest), rank the student in the following qualities and include an explanation of your score.
Student’s motivation and maturity (please rank and explain):
Student’s ability to handle ambiguity (please rank and explain):
Student’s ability to collaborate in a team environment (please rank and explain):
Describe one quality that you feel this student needs to improve on (please explain):
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
MEDICAL HISTORY AND RELEASE
Participant Name ______________________________________________________________
FIRST NAME
MIDDLE NAME
LAST NAME (AS ON PASSPORT)
Emergency Contact Information (All participants must complete this section of the form.)
Name ________________________________________________________
Relationship to Participant _____________________
Phone __________________________
Alternate Phone ___________________
Street Address ________________________________________________________________
City _______________________ State/Province ____________
Country ________________
Email Address _________________________________________________________________
Participant Medical History
All participants must complete this section of the form. If one does not apply to you, please list “none.”
Birth Date _____________
Age ______
Blood Type ____________
Height ____________
Do you smoke?
Date of Last Tetanus Toxoid __________
Weight ________
Yes  No
Past Health Concerns/Injuries _____________________________________________________
Present Health Conditions_________________________________________________________
Allergic Reactions________________________________________________________________
Present Medications (Name, Dosage, Reason for Taking) ________________________________
________________________________________________________________________________________
____________________________________________________________________
Please list any special conditions you are aware of or have been told by a physician that we should be aware of (i.e., injuries,
past surgeries, arthritis, asthma, heart disease, high blood pressure, pregnancy, etc.)
__________________________________________________________________________
__________________________________________________________________________
I hereby agree that the information provided above is true to my knowledge.
___________________________________________ _____________________
PARTICIPANT SIGNATURE
DATE
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
ASSUMPTION OF RISK AND RELEASE FROM LIABILITY
WHEREAS, The Trustees of Indiana University, through its Kelley School of Business, department of Institute for International
Business is arranging field trips in Indiana for the purpose of: business and U.S. cultural education throughout the Global
Business Institute from
June 22 – July 19, 2014 and WHEREAS, I, ______________________________, wish to participate in the Field Trips, and
Participant Name
NOW THEREFORE, in consideration of University's services rendered and services to be rendered in organizing the Field Trip and
in consideration of my participation in the Field Trip, I hereby:
1.
State that I understand that certain risks are inherent in travel and that I fully accept those risks. These risks may include,
but are not limited to, such things as incidents related to transportation, adverse weather conditions, and other physical,
mental, and emotional injury;
2.
State that I understand that certain risks are inherent in participation in field trips, and that I fully accept those risks. These
risks may include, but are not limited to, such things as exposure to adverse weather conditions, sprains, broken bones,
cuts, bruises, entrapment, and other physical, mental, and emotional injury;
3.
State that I fully understand the risks and the scope of the activities involved in the Field Trip, and I agree to assume the
risks of my participation in the Field Trip, including the risk of catastrophic injury or death;
4.
Release and fully discharge The Trustees of Indiana University, its officers, agents and employees, from all liability in
connection with my participation in the Field Trip, for or on account of any injury to or illness of my person or death, or
for or on account of any loss or damage to any personal property or effects owned by me.
PARTICIPANT SIGNATURE: ___________________________
DATE: _____________________________
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
GBI PHOTO COMPOSITE
The GBI Photo Composite is a publication that will include photographs and biographical information about
each participant.
Name ________________________________________________________________________
MIDDLE NAME
FIRST NAME
LAST NAME (AS INDICATED ON PASSPORT)
Preferred Name (If different than above) _____________________________________
Hometown (City, Country) ________________________________________________________
Academic Institution __________________________ Major/Concentration _______________
Personal Interests or Hobbies (list up to four)
__________________________________
___________________________________
___________________________________
___________________________________
 I give permission for my photo and biographical information to be included in the GBI Photo Composite
____________________________________________
_____________________
PARTICIPANT SIGNATURE
DATE
Example
Name Mohamed
FIRST NAME
Raafat
MIDDLE NAME
El Habiby
LAST NAME (AS INDICATED ON PASSPORT)
Preferred Name (If different than given surname) Mohamed Raafat
Hometown (City, Country) Alexandria, Egypt
Academic Institution
Ain Shams University
Major/Concentration Engineering
Personal Interests or Hobbies (list up to four)
Swimming
Hiking
Reading
Football
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
PHOTO AND VIDEO RELEASE
Participant Name ______________________________________________________________
FIRST NAME
MIDDLE NAME
LAST NAME (AS INDICATED ON PASSPORT)
I hereby grant to Indiana University the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of
university related photographs or videotaped images of the undersigned student for use in connection with the activities of the
university or for promoting, publicizing or explaining the school or its activities. This grant includes, without limitation, the right to
publish such images in the university’s student newspaper, alumni/ae magazine, on the university’s Web site, and public
relations/promotional materials, such as marketing and admissions publications, advertisements, fund-raising materials and any
other university-related publication. These images may appear in any of the wide variety of formats and media now available to the
school and that may be available in the future, including but not limited to print, broadcast, videotape, CD-ROM and
electronic/online media. All photos taken are without compensation to me (the undersigned). All electronic or non-electronic
negatives, positives, and prints are owned by the university.
I hereby acknowledge that I have read and understand the terms of this release.
____________________________________________
_____________________
PARTICIPANT SIGNATURE
DATE
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
ADDITIONAL INFORMATION
Participant Name ______________________________________________________________
FIRST NAME
MIDDLE NAME
LAST NAME (AS INDICATED ON PASSPORT)
Dietary Preferences, Allergies and Restrictions (Please check all that apply)
No Fish
Vegetarian
Halal
Dairy-Free (Lactose Intolerant)
Other ______________________________________
Check here if you have special needs that might require accommodations to fully participate in the program.
A staff member will contact you.
T-Shirt Size (American t-shirt sizes are typically one size larger. For example, if you normally wear a large
indicate medium below)
Extra Small
Small
Medium
Large
Extra Large
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
Extra Extra Large
Bradford Woods--Indiana University’s Outdoor Center
Participation Agreement
Program Name: Global Business Institute
Program Dates: June, 2015
Please fill out this form thoroughly. We will use the information provided to plan a safe and enjoyable experience. This also serves as a
helpful reminder to you of physical precautions and care you may need to take because of previous injuries and other physical conditions
you may have. Any information disclosed on this form will remain confidential.
Participant Information:
Name_____________________________________________________________________ □ Male □ Female
Address__________________________________________________________ Date of Birth______/_______/_______
City______________________________ State_________ Zip______________ Phone (______) __________________
In Case of Emergency:
Notify (Name):__________________________________________ Relationship to participant ____________________
Address __________________________________________________________ Phone (______) __________________
Name of Physician__________________________________________________ Phone (______) __________________
Physician’s Address___________________________________________________________________________________________
Insurance Company___________________________________ Policy Number_________________________________
Medical Information:
Blood Type________ Height________ Weight________ Allergies_____________________________________________
Describe allergic reaction: ____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Specific Dietary needs: ______________________________________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________
Current medications (name, dosage, reason for taking): _____________________________________________________
______________________________________________________________________________________________________________
____________________________________________________________________________________
Please list any special conditions you are aware of or have been told by a physician that we should be aware of (i.e., injuries, medical
diagnosis, past surgeries, arthritis, asthma, heart disease, high blood pressure, pregnancy, etc.)
______________________________________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________________________
Medical Services Permission Release
During the participation in a Bradford Woods’ program, the Trustees of Indiana University, its agents, servants, and employees are hereby
authorized to provide and secure any medical services, and authorize the diagnosis and treatment (including, but not limited to, surgery
and the administering of anesthesia) of any injury or illness as in its judgment is necessary or advisable for the individual. I hereby agree
that the MEDICAL HISTORY provided above is true to my knowledge. I declare that I have read and understand the contents of this
MEDICAL SERVICES PERMISSION and I am signing this as my free and voluntary act, irrevocably binding myself and my heirs.
______________________________________________________
Participant Signature (Legal guardian’s signature if participant is under 18)
___________________________
Date
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
Global Release
Program Name: Global Business Institute
Program Dates: June, 2015
Indiana University, through its Bradford Woods programs (hereinafter referred to as University), manages and conducts
adventure and outdoor based programs consisting of but not limited to: ground based initiatives, individual and group challenge
activities, low, intermediate, and high ropes courses, hiking, camping, backpacking, caving, canoeing, other water based activities,
fishing, archery, arts and crafts, environmental nature studies, service projects, transportation to and from activity sites and all other
activities. These activities are supervised by University staff, interns, and school personnel.
Although novice skills will be taught and supervised by competent and experienced adult leaders, there is some degree of
risk involved in the various activities and the ultimate safety of each participant will depend on the participants willingness to listen
and to abide by the instructions, rules, and regulations given throughout the program.
The safety and well-being of each participant is of paramount importance to Bradford Woods and the professional staff,
employees, and trustees of Indiana University. All reasonable care and precautions are taken to ensure a fun educational
experience. The following “acknowledgment, assumption of risk and release of claims” is both a requirement of insurance coverage
and an important reminder to you as a parent / guardian or participant to be sure that you or your child is properly prepared.
Acknowledgement, Assumption of Risks and Release of Claims Release
I, or my child desire to participate in the program specified above. I understand the program offered through Bradford Woods will take
place in a wilderness environment and may include, but is not limited to, the following potential hazardous activities: ground based initiatives,
individual and group challenge activities, low, intermediate, and high ropes courses, hiking, camping, backpacking, caving, canoeing, other water
based activities, fishing, archery, arts and crafts, environmental nature studies, transportation to and from activity sites and all other activities. The
inherent risks of these activities include the following: personal injury, property damage, illness, or death.
I understand that Bradford Woods does not require that I participate in the above-mentioned program. In recognition of the potentially
hazardous nature of the elective program, I, or my child, my heirs and assigns, hereby release Bradford Woods and the professional
staff, employees, the trustees of Indiana University, and its agents from all claims of negligence arising from participation in the
program. I further agree to hold harmless and indemnify Bradford Woods and the professional staff, employees, the trustees of Indiana
University, and its agents for all defense costs, including attorney fees, and any other costs resulting in connection with my
participation in this program.
I understand that this release relates to all claims and liability during and after the program resulting from a pre-existing medical
condition. I have read and completed the medical history form provided by Bradford Woods and accept full responsibility for omissions or errors on
the medical history form. I also understand that this release relates to all claims and liability resulting from unforeseen or intemperate weather. I
have read the clothing list provided by Bradford Woods and accept full responsibility for inadequate clothing provided by me or those items which I
fail to provide.
I have read this entire “acknowledgement and assumption of risk and release of claims” and fully understand the contents. My
signature indicates that I have satisfied my questions and concerns regarding the above-mentioned program by talking with a
representative of Bradford Woods.
___________________________________________________________
Signature (Legal guardian’s signature if participant is under 18)
Date
_________________________
Participant
Photographic Release
I hereby grant the University permission to take photographs, video recordings, and/or sound recordings of myself or my son or
daughter. I grant the university permission to use the negatives, prints, motion pictures, video tapings, or any other reproduction of the same for
educational and promotional purposes in manuals, on flyers, on the internet, or in any other manner deemed necessary.
I declare that I have read and understand the contents of this PHOTOGRAPHIC RELEASE, and I am signing this as my free and
voluntary act, irrevocably binding myself and my heirs.
____________________________________________________________
Signature (Legal guardian’s signature if participant is under 18)
Date
_________________________
2015 Coca-Cola MENA Scholarship Program
Classified - Unclassified
Participant