The Diana Kamal Scholarship Search Fund

Academic Year 2014 - 2015Application

STUDENT’S NAME AS IT APPEARS ON THE PASSPORT

First Name Middle Name Family Name

Name of School Current Grade Level

Date of Application

Deadline is October 1st, 2013

Personal Data

Name: _____________________________________________________________________________________First Name Middle Name Last Name

Gender: Female Male

Do you ever spell your name differently? If so, how: ________________________________________________

Email:

Home Telephone: Cell Phone: _________________ Fax:

Address:

City: Province or Region: Country:

Country of Permanent legal residence:

Citizenship(s): 1 2 3

Birth Date: / / City of Birth: Country of Birth: Day Month Year

Family Data

Father Last Name: First name:

Occupation: Telephone: ____________________________

Company\Organization\Ministry: __________________________________________________

Mother Last Name: First Name: ___________________________

Occupation: Telephone:

Company\Organization\Ministry: __________________________________________________

Student lives with: Both Parents Mother only Father only Other: _________________

Parents are: Married Separated Divorced Other: _______________________________

Family Name Sex Age Relationship Grade levelMembers:

1.

2.

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3.

4.

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Extracurricular, Personal, and Volunteer Activities

Interests and Hobbies

List all extracurricular activities and all hobbies in which you have participated. Please state if you have received any awards, or if you have any outstanding achievements in these activities. Start with the most recent. You can attach a list or summary of your activities on a separate sheet if you like, and please be sure to highlight any leadership roles.

ActivityNumber of Hours per

Week

Month/Year Started

Month/Year Ended Name of Award Reason for Receiving

AwardDate

Received

      

       

       

       

Educational Data

School Name: _______________________________________________________________________________

Address: __________________________________________ Telephone: _______________________________

Name of Principal: ___________________________ Type of School: Public Private

Language Proficiency

Native language(s): ___________________________________________________________________________

Number of years of English study: _____________________ Academic Institutions: ________________________

Knowledge of foreign languages, including English (Rate your abilities as Excellent, Good, or Fair):

Language Reading Ability Writing Ability Speaking Ability

Academic Honors - List any honors or distinctions you have been awarded since the 9th and\or 10th and\

or 11th grade:

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Test Information

Please indicate your highest TOEFL-iBT, SAT Reasoning Test and SAT Subject Test scores:

Test Name Date taken or to be taken Score

TOEFL-iBT

SAT Reasoning Test / ACT TestVerbal Section: Quantitative Section: Writing Section:

SAT Subject Test Subject I: Subject II: Subject III:

Short Essays

Please write an essay of 250-300 words maximum for each of the following topics:

1. Why do you think you qualify to apply to Diana Kamal Scholarship Search Fund?

2. Describe two challenging moments\incidents you experienced throughout the past year and how did you

handle them?

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Confidential Teacher Evaluation

To the applicant: Fill in your name below and give this form to a teacher of any subject other than English.

Student Name ________________________________________________________________________________First Middle Family Name

-----------------------------------------------------------------------------------------------------------------------------------To the Teacher: All evaluation forms should be completed, signed, and then returned to the student in a sealed envelope for submission with his or her application.

Teacher’s Name: _____________________________________ Position ___________________________________

Secondary School Name: _________________________________________________________________________

School Address: ________________________________________________________________________________

Phone(s): _____________________________________ Teacher’s E-mail __________________________________

Signature _____________________________________ Date ____________________________________________

Background Information

How long have you known this student? ________ Years

What subject(s) did you teach this student? ___________________________________________________________

What are the first words that come to your mind to describe this student?

__________________ __________________ __________________ _______________

__________________ __________________ __________________ _______________

__________________ __________________ __________________ _______________

__________________ __________________ __________________ _______________

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Rating: Please rate this student as they compare to other students in their class (place an X or check mark in the box that applies under each category):

Outstanding Excellent Good Fair Poor Unable to Judge

Academic Performance

Intellectual Ability

Academic Motivation in School

Resourcefulness & Initiative

Leadership Qualities

Ability in oral expression

Ability in written expression

Adaptability to new situations

Honesty and Integrity

Respect for AuthorityRelationship with other students and peers

Evaluation Please write a minimum of 7 sentences describing the student’s academic and personal characteristics. We are particularly interested in the candidate’s intellectual promise, motivation, maturity, integrity, independence, leadership potential, capacity for growth, special talents, enthusiasm, and concern for others. We welcome information that will help us to differentiate this student from others.

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Confidential English Teacher Evaluation

To the applicant: Fill in your name below and give this form to your English teacher.

Student Name _______________________________________________________________________________First Middle Family Name

------------------------------------------------------------------------------------------------------------------------------------------To the Teacher: All evaluation forms should be completed, signed, and then returned to the student in a sealed envelope for submission with his or her application.

Teacher’s Name: ____________________________ Position ___________________________________________

Secondary School Name: ________________________________________________________________________

School Address ________________________________________________________________________________

Phone ________________ _________________ Teacher’s E-mail _______________________________________

Signature ____________________________________ Date ____________________________________________

Background Information

How long have you known this student? ________ Years

What subject(s) did you teach this student? ___________________________________________________________

What are the first words that come to your mind to describe this student?

__________________ __________________ __________________ _______________

__________________ __________________ __________________ _______________

RATINGS: Compared to other students in his/her class, how do you rate this student in terms of the following (place an X or check mark in the box that applies under each category):

Outstanding Excellent Good Fair Poor Unable to Judge

Overall English abilities

Reading Comprehension in English

Writing Effectively in English

Fluency in speaking English

Listening skills in English

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EVALUATION Please write a minimum of 7 sentences describing the student’s academic and personal characteristics. We are particularly interested in the candidate’s intellectual promise, motivation, maturity, integrity, independence, leadership potential, capacity for growth, special talents, enthusiasm, and concern for others. We welcome information that will help us to differentiate this student from others.

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Secondary School Report

To the applicant: Fill in your name and give this form to your guidance counselor or principal:

Student Name: _________________________________________________________________________________ First Middle Family Name

------------------------------------------------------------------------------------------------------------------------------------To the Secondary School Guidance Counselor or Principal: Please attach the student’s official transcript, including courses in progress, and a school profile.

Class Rank _____________ in a class of __________, covering a period from ______________ to _______________

Cumulative GPA or Average __________ on a ______ scale, covering a period from _________to _______________

Graduation date: ___________

Counselor’s/ Principal’s Name_____________________________________________________________________

Signature ____________________________________ Date ____________________________________________

Position _____________________________________ School___________________________________________

Address _____________________________________ Email ___________________________________________

Phone _______________________________________ Fax _____________________________________________

How long have you known this student? ________ Years

What are the first words that come to your mind to describe this student?

__________________ __________________ __________________ _______________

__________________ __________________ __________________ _______________

Ratings: Compared to other students in his secondary school class, how do you rate this student in terms of the following (place an X or check mark in the box that applies under each category):

Outstanding Excellent Good Fair Poor Unable to Judge

Academic Performance

Intellectual Ability

Academic Motivation in School

Resourcefulness & Initiative

Leadership Qualities

Adaptability to new situations

Honesty and Integrity

Respect for Authority

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Relationship with other students/peers

EVALUATION Please write a minimum of 7 sentences describing the student’s academic and personal characteristics. We are particularly interested in the candidate’s intellectual promise, motivation, maturity, integrity, independence, leadership potential, capacity for growth, special talents, enthusiasm, and concern for others. We welcome information that will help us to differentiate this student from others.

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Financial Information Section

1. How many people, including yourself, depend on the income of your parents for daily living expenses? ______

2. In 2012, how much household income did your family receive from the following sources? (Please indicate yearly amount for each category in US dollars.)

a. Father’s annual income $ _____________

b. Mother’s annual income $ _____________

c. Your work / internship $ _____________

d. Family business $ _____________

e. Family real estate holdings $ _____________

f. Pension $ ______________

g. Other members of the household $ ______________

h. Other (explain) $ ______________

TOTAL YEARLY INCOME $ ______________

3. Will there be a significant increase or decrease in your family’s income next year?

No

Yes

If yes, please explain: _____________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

4. Enter the amount of yearly support you can count on for your university costs from the sources listed below:

Sources 2011-12 2012-13 2013-14 2014-15Student's vacation earnings U.S. $ U.S. $ U.S. $ U.S. $

Student's assets or income U.S. $ U.S. $ U.S. $ U.S. $

Father’s and mother’s incomes U.S. $ U.S. $ U.S. $ U.S. $

Family's assets (savings, investments, business, etc.)

U.S. $ U.S. $ U.S. $ U.S. $

Relatives and friends U.S. $ U.S. $ U.S. $ U.S. $

Private sponsor U.S. $ U.S. $ U.S. $ U.S. $

Other U.S. $ U.S. $ U.S. $ U.S. $

5. Explanation/ Special Circumstances: Explain any unusual expenses, debts, or special circumstances that the Diana Kamal Scholarship Search Fund committee members, should consider regarding your financial situation.

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