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CHRISTINA McCONNELL SCHOLARSHIP APPLICATION

(Ugandan Nationals Only)

TYPE OR CLEARLY PRINT ALL INFORMATION IN BLACK/BLUE INK. Place current
passport
All four parts of the application must be completed and submitted with a copy of size photo
the birth certificate/passport by February 25th, 2019. Incomplete applications will here
not be forwarded to the scholarship committee. This Scholarship application
form has been designed to give each applicant fair and equal consideration. The
scholarship is awarded based on financial need and student merit. Please
complete the form as accurately as possible and return via email to
[email protected].

All information given will be held in strict confidence and will be used by school officials only.

An incomplete application will not be considered.

PART 1. PERSONAL INFORMATION

STUDENT INFORMATION

Student’s full name_____________________________________________________________________

Surname Other Names

Male______ Female______ Age ______ Birth Date (MM/DD/YYYY)__________________________

Place of Birth:
Region _____________________________________ District __________________________________

Sub County _________________________________ Village __________________________________

Country of Birth _____________________________ Nationality _______________________________

Do you have a birth certificate or passport? _________

If Yes, please provide details ____________________________________________________________

Current Address: _________________________________________ P.O Box _____________________

City: ________________________________ Region/Sub County: ______________________________

Telephone (student): __________________________________________________________________

Email (student): ______________________________________________________________________

What languages do you speak? ____________________________ Fluent in English? Yes____ No ____

Have you lived or studied in another country? ______________

If yes, please describe: _________________________________________________________________

___________________________________________________________________________________

Areas of specific academic interest: _______________________________________________________

REV FEB 2019

PARENT / GUARDIAN INFORMATION (if deceased include date of death)

Father/Guardian’s Name Mother/Guardian’s Name

Father/Guardian’s Nationality Mother/Guardian’s Nationality

Father/Guardian’s ID Number Mother/Guardian’s ID Number

Telephone Contacts Telephone Contacts

Email address Email address

Father/Guardian’s Address (if different from applicant) Mother/Guardian’s Address (if different from applicant)

Please list the preferred email address for receiving communication from ISU

Other family members:
Sisters (and ages): ______________________________________________________________________
_____________________________________________________________________________________

Brothers (and ages): ____________________________________________________________________
_____________________________________________________________________________________

Other: _______________________________________________________________________________

Who has legal custody of the student?

RESIDENCE

With whom does the student live with in Uganda?
Name: __________________________________
Relationship to student: _____________________________ (E.g. mother, father, guardian, grandparents)
Place of Residence: ____________________________________________________________________
_____________________________________________________________________________________
Name & Telephone Contact of LC1 Chairperson: ______________________________________________

EMERGENCY CONTACT INFORMATION IN KAMPALA

Please name an adult in Kampala, other than the parents/guardians, who can be contacted in case of an

EMERGENCY.

Name: Relationship:

Physical Address in Kampala:

P. O. Box: Telephone Contact:

Mobile: Email address:

REV FEB 2019

EDUCATION BACKGROUND
Name of School Currently Attending or where you did your UCE exams

Current Class / Form in School

School Address

School Telephone School Email Address

School Principal / Headmaster Name

School ID Number

Who currently pays your school fees? (In the case of an organisation please state name and contact
details)

What were your results in the 2017 UCE exams? Grade:
English
Maths
Biology
Chemistry
Physics
History
Geography
Commerce
Other

Total Aggregate:

PART 2. WRITTEN TASKS

The application packet is incomplete without the responses to each of these items. For each
prompt, use the allocated space or submit a separate document identifying each written part to
which you are responding to (include your name and school on every page). Your work should be
neat, grammatically correct, and demonstrate proficiency in English.

Extra Curricular Activities – please list all activities you participated in at school e.g. football/netball, track
and field, drama, music, etc.

REV FEB 2019

Leadership – do you / have you held a leadership position within your school or community e.g. team
captain.

Future Goals – what is your career ambition and why?

Future Goals – where do you see yourself in 10 years’ time?

PART 3. SCHOOL REPORT / TRANSCRIPTS / DOCUMENTATION

Please ask your school to provide you with a copy of your academic records to date. This should list the
classes that you have taken and your final scores for each class you have completed in the last three years.
Please attach this and the following to this application:

1. O Level UCE certificate – certified copies
2. Past school reports - certified copies
3. School ID copy
4. Birth Certificate / Passport copy
5. Letter of recommendation from current School Principal / Headmaster
6. Character reference from recommending organisation (required for initial application)

REV FEB 2019

PART 4. FINANCIAL INFORMATION

Total Household Income Per Year
Family Assets and Value
Household Liabilities / Loans
Cost of Student Education
Other information

How did you learn about the ISU Scholarship?
____ Newspaper ____ ISU Website ____ Notice Board _____Social Media
Word of Mouth Other (please specify) ______________________________________________________

STUDENT APPLICANT’S STATEMENT AND SIGNATURE:

I certify that to the best of my knowledge all the information I have provided is accurate and that
the work I have submitted is my own.

APPLICANT’S SIGNATURE: ________________________________ DATE: _________________

PARENT / GUARDIAN’S STATEMENT AND SIGNATURE:

I certify that the information I have given is true in all respects and that I understand that if any
information so given is found to be false, the Scholarship will cease immediately and the school
will take whatever action necessary to recover amounts disbursed.

I understand that if given the Scholarship the student will be required to meet requirements for
academic work and appropriate behaviour.

I understand that the approval of a Scholarship for this year in no way obligates ISU to continue
with scholarships in subsequent years.

Each year renewals will be made and set on the basis of the demonstrated applicant’s
achievements.

FATHER / GUARDIAN’S SIGNATURE: ________________________ DATE: _________________
MOTHER / GUARDIAN’S SIGNATURE: _______________________ DATE: _________________

REV FEB 2019