2015 coca-cola mena scholarship application

2015 Coca-Cola MENA Scholarship Program

Application Completion Checklist (Must be completed in English)

Candidate Name(Full Name as it appears in passport)

Nadeem Riaz

Name of University(Currently enrolled in)

University of Engineering & Technology, Taxila

Year of Study 3rd

Concentration Area of Study

Mechanical Engineering

E-Mail Address [email protected]

Home Address Mohallah Ghousia Jand Tehsil & P/O Jand Distt. Attock

Age 20

Gender Male

City and Country Attock, Pakistan

Occupation Student

In order for your application to be complete, please make sure you submit:

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)


Classified - Unclassified

* All applications must be received via e-mail by February 6 th , 2015. Any applications received after this time will not be considered. Please e-mail applications to:

[email protected]

2015 Coca-Cola MENA Scholarship ProgramApplication Form

NAME: ___Nadeem______________________________________________________Riaz_______________ (First) (Middle) (Last name as indicated on passport)

CONTACT INFORMATIONMailing Address(if different from home address)

Al-Madina General Store Near New Baraf Khana Makhad Road Tehsil & P/O Jand Distt. Attock

CellPhone

+923125011104 HomePhone

+9257-2621810

WorkPhone

PERSONAL DATA

Gender Male Female

Date of Birth (Month, Day, Year)

May 27, 1994 Place of Birth(City, Country

Attock, Pakistan

Country of permanent legal residence

Pakistan Country of citizenship

Pakistan

Dual Citizenship? Yes No If yes, indicate country

Year of Study (check one)

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 N/A



mailto:[email protected]

** MILITARY EXEMPT PERMISSION FORMS MUST BE COMPLETED PRIOR TO TRAVEL.

ENGLISH LANGUAGE PROFICIENCY

Number of years of English Study: 12

Where Studied: Pakistan

Reading proficiency (check one) Excellent Good Fair

Writing proficiency (check one) Excellent Good Fair

Speaking proficiency (check one)

Excellent Good Fair



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/YYFrom: 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 DatesMM/YY – MM/YY

Travel Purpose(e.g. vacation, school, etc.)

US Government

Program? Y/N

From: To: From: To:



From: To:



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.




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):



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 HistoryAll participants must complete this section of the form. If one does not apply to you, please list “none.”

Birth Date _____________ Age ______ Date of Last Tetanus Toxoid __________Blood Type ____________ Height ____________ Weight ________

Do you smoke? 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



ASSUMPTION OF RISK AND RELEASE FROM LIABILITYWHEREAS, 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: _____________________________



GBI PHOTO COMPOSITE

The GBI Photo Composite is a publication that will include photographs and biographical information about each participant.

Name ________________________________________________________________________FIRST NAME MIDDLE 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



ExampleName Mohamed Raafat El Habiby

FIRST NAME MIDDLE NAME 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 Reading Hiking Football

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



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 Extra Extra Large



Bradford Woods--Indiana University’s Outdoor CenterParticipation 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 ReleaseDuring 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 Global Release

Program Name: Global Business Institute Program Dates: June, 2015Indiana 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 ReleaseI, 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.

___________________________________________________________ _________________________ Participant Signature (Legal guardian’s signature if participant is under 18) Date

Photographic ReleaseI 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.

____________________________________________________________ _________________________ Participant Signature (Legal guardian’s signature if participant is under 18) Date



2015 coca-cola mena scholarship application

Documents

country year of study

english study

previous travel

home country

travel experience

application checklist

application p

pakistan reading proficiency