Helene D. Stoneman Scholarship

and Civic Leadership Program

2016Application Form

Applications are due MondayNovember 21, 2016

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: ____ZIP: ______

Phone: (_____) ______Email: ______

Gender(optional):___ Female ___ MaleAge (optional): ______

Race (optional):___ African American ___ Asian American ___ Native American

___ White ___ Hispanic ___ Multi-Racial___ Other

YOUTHBUILD PROGRAM STUDENT DATA

Please include a copy of an officialhigh 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 2016 __ 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 yourcollege’s official transcript.

Expected date of graduation: ____ Month _____ Year

Degrees Completed

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s ______Other

Date degree received: ____ Month _____ 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’sofficial transcript.

Date of graduation: ____ Month _____ Year

Degrees sought:

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s______Other

Degrees Completed

___ Associate’s ___ Bachelor’s ___ Master’s___ Doctor’s ______Other

Date degree received: ____ Month _____ Year

FINANCIAL INFORMATION
Your Financial Resources

Describe

Scholarships$______

Grants$______

Segal AmeriCorps Ed.Award$______

IDA$______

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____ NO

If YES, please check one:____ part-time____ full-time

Employer:______

Job Description:______

______

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___ Other

Name of OrganizationCityStateActivities

______

______

______

______

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 ___Other YouthBuild Leadership Positions

___ Other Organizations

Name of OrganizationCityStateActivities

______

______

______

______

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___ Alumni Xchange ___ Non-YouthBuild Leadership Events

Please Describe: ______

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______

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: ______City, State: ______

Activities: ______

______

______

Name of Organization: ______City, State: ______

Activities: ______

______

______

Name of Organization: ______City, State: ______

Activities: ______

______

______

Name of Organization: ______City, State: ______

Activities: ______

______

______

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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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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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.

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 MondayNovember 21, 2016

EMAIL:Charles Clark,

MAIL:YouthBuild USA

Attn: Charles Clark

Vice President for Asset Development

58 Day Street

Somerville, MA 02144

TEL: Charles Clark, 617-741-1288

FAX: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 ______

RecommendingYouthBuild Staff Name______

Title ______YouthBuild ______

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 LeadershipProgram at 617-623-9900 during regular YouthBuild USA business hours.

This Statement Has Been Updated Through April 30, 2011.

2016Helene D Stoneman Scholarship Application