DO NOT STAPLE

For GSP Office Use Only

Journal No.		

Region			

Focus		_______
Areas:                
                          _______
		
                          _______

2019 Governor's Scholars Program
Student Application Form

IMPORTANT: Keep a copy for your records.

***Application Must Be TYPED 
School District
     	High School
         	
County of Residence 
          	School County
          	
Student Information:	
First Name
          	Middle Name
          	Last Name
          	
Preferred Name
               	Email:
          	
Address (Street/Route/Post Office Box)
          	City
          	State
       	Zip
          	
Phone
(   )     -        	Birth Date (MM/DD/YY)
    /     /   	
Parent/Guardian Information (Please Note: Correspondence from our office will be addressed as listed below)	
1. Full Name (With Title: i.e., Mr./Mrs., Dr., Rev., etc.) 
          	Primary Phone 
(   )     -      	
Home Address (Type SAME if address is same as applicant’s)
          	City
          	State
       	Zip
          	
Place of Employment 
          	Secondary Phone 
(   )     -        	
Occupation and Title 
          	Email
          	
	
2. Full Name (With Title: i.e., Mr./Mrs., Dr., Rev., etc.) 
          	Primary Phone 
(   )     -      	
Home Address (Type SAME if address is same as applicant’s)
          	City
          	State
       	Zip
          	
Place of Employment 
          	Secondary Phone 
(   )     -        	
Occupation and Title 
          	Email
          	

The following information is requested for statistical purposes.

Sex:	  Female	Race/Origin:	 White	     Hispanic		     Black/African-American
	   Male			  Asian	      Native American	     Other (specify)            

Student’s Name:      

2019 FOCUS AREAS

	Indicate below three preferences for the focus area that you would like to study.  Before making your choices, please read the Statement of Curriculum, which describes each focus area in more detail.  Choose subjects that you would like to know more about.  Do NOT choose subjects in which you feel deficient in the hope of improving your skills with summer study.  You may wish to consult your teachers, families, and others before listing your preferences.

	Every effort will be made to provide you with one of your three choices.  If accepted, you will receive a letter from your instructor before the program opens describing in greater detail what your focus area will encompass.

	Subjects may be presented in a variety of non-traditional and interdisciplinary ways that may differ from what you expect or have experienced.  Remember, courses are offered for academic enrichment, not for advanced skill training.

OF THE FOLLOWING CHOICES, CHOOSE ONLY 3

Indicate your three choices by marking an “X” before the name of the focus area.

 Agribusiness/Biotechnology (1)

  Architectural Design (2)	
				  
  Astronomy (3)	
						
  Biological & Environmental Issues (4)

  Business, Accounting & Entrepreneurship (5)

  Communication & Social Theory (6)

  Creative Writing & Literary Studies (7)

  Cultural Anthropology (8)	

 Dramatic Expression (9)

  Engineering (10)

  Film Studies (11)

  Forensic Science (12)

  Healthcare Industry (13)

  Historical Analysis (14)

  International Relations (15)

  Journalism & Mass Media (16)	

  Modes of Mathematical Thinking (17)

  Music Theory & Performance (18)

  Philosophy (19)

  Physical Science (20)

  Political & Legal Issues (21)

  Psychology & Behavioral Studies (22)

  Spanish Language & Culture (23)
        (Requires a minimum of one-year of previous study.)

  Visual Arts (24)

Student’s Name: ________________________________________

5.	Student Consent and Agreement

If accepted, I commit to remain in the program for the entire five weeks without interruption and to abide by its rules.  I attest that the information provided by me in this application is correct, and that the writing entry is my original work.

Student’s Signature:  ________________________________	Date: ___________________________		

6.	Parental Consent
		
	As parent or legal guardian, I give consent for  ______________________________ to participate for the full five weeks in the Governor's Scholars Program and to abide by its rules and regulations.  I also give my consent for the release of school records and test scores to those involved in the overall selection process for Governor's Scholars and to those administering, teaching, and counseling in the Governor's Scholars Program.

	Parent or Legal Guardian’s Signature:  _________________________________	Date: __________________

The results of the selection process are final.

The superintendent/principal is responsible for forwarding only one copy of each candidate’s entire application, including all attachments, to the Governor’s Scholars Program, Student Applications, 1024 Capital Center Drive, Suite 210, Frankfort, Kentucky, 40601.  Principals/Guidance Counselors of participating schools in a district should be notified of the final selections of the school district.  

Final selections of Governor's Scholars will be made on the recommendation of a Statewide Selection Committee.  All candidates competing at the statewide level will be notified directly by the Governor's Scholars Program of their status (Accepted, Alternate, or Not Accepted).   

Notice of Nondiscriminatory Policy as to Students

The Governor's Scholars Program does not discriminate on the basis of race, sex, color, physical capabilities, national and ethnic origin, religion, sexual orientation, gender identity, or age in administration of its educational or admission policies.  All admitted students are granted the rights and privileges generally accorded or made available to high school students while participating in the program.

THIS SECTION IS TO BE COMPLETED BY THE COUNSELOR.

Please attach to this application a photocopy of the student’s official test score and transcript.

Counselor Name:                                     _		Phone:	         _________________                                

ACT:

Year Taken:       

Composite:       

	
PSAT:

Year Taken:             

Selection Index:        

       SAT:

Year Taken:       

Total:                   
	
Unweighted
GPA:

____   _______
Based on 4.0 scale
	
Difficulty of Course Load:

• 1 - 
• 2 - 
• 3 - 
• 4 - 
• 5 - 

(See below for instructions)	

Instructions for Ranking Difficulty of Course Load:

1.	This student has taken only the required curriculum in lower level classes and has not selected any academic subjects as electives.

2.	This student has taken at least one honors or advanced class or at least one class in the higher level if honors or advanced is not available and has not selected academic subjects as electives.

3.	This student has taken at least two honors or advanced courses or two courses in the higher level of courses if honors or advanced are not available.  The student must have taken some academic courses as electives.

4.	This student has taken three or more honors or advanced courses or three or more courses in the higher level courses if honors and advanced are not available.  The student must have chosen academic courses as electives and taken 1 year of foreign language. *

5.	This student has taken honors or advanced courses in most/all subjects offered or at the highest level of courses offered in those schools without honors or advanced courses.  Student must have chosen academic courses as electives and taken 2 years of a foreign language.*

*Note regarding foreign language requirement:  In schools where students are unable to take 2 years of foreign language by their junior year, one year will suffice.  Additionally, if foreign language is postponed in lieu of AP or equivalent academic courses, students should not be penalized. 

If a GSP School Coordinator has any questions regarding the foreign language requirements, please contact the Governor’s Scholars Program office by calling 502-573-1618.

STUDENT PROFILE

1.	Extracurricular Activities – List the activities in which you have been involved and provide a description of your contribution to that activity.  Activities can reflect participation in school, church, community, and civic functions or a personal talent during the 9th, 10th & 11th grades.  Activities from the summer prior to entering the 9th grade can and should be included.  Your description should include:  what responsibilities you assumed, the importance of your role, how much time you committed to the activity, and how often you participated.  Do not abbreviate activity names.  (Additional page may be attached if needed.) 

	Review our “Helpful Hints: Best Practices & Important Information” document to find samples 	and examples for this section.

A.   Activity:     	Grades:     	
Contribution:     	
B.   Activity:     	Grades:     	
Contribution:     	
C.   Activity:     	Grades:     	
Contribution:     	
D.   Activity:     	Grades:     	
Contribution:     	
E.   Activity:     	Grades:     	
Contribution:     	
F.   Activity:     	Grades:     	
Contribution:     	
G.   Activity:     	Grades:     	
Contribution:     	
H.   Activity:      	Grades:     	
Contribution:     	
I.   Activity:     	Grades:     	
Contribution:     	
J.   Activity:     	Grades:     	
Contribution:     	
K.   Activity:     	Grades:     	
Contribution:     	
L.   Activity:     	Grades:     	
Contribution:     	
M.   Activity:     	Grades:     	
Contribution:     	
N.   Activity:     	Grades:     	
Contribution:     	
O.   Activity:     	Grades:     	
Contribution:     	
P.   Activity:     	Grades:     	
Contribution:     	
Q.   Activity:     	Grades:     	
Contribution:     	
STUDENT PROFILE (continued)

2.	Service (voluntary or paid) – List your volunteer or paid service from the 9th, 10th, and 11th grades.  Explain your specific responsibilities and the impact these experiences have had on your awareness, growth, and development.  In doing so, you will be able to demonstrate the depth and breadth of your commitment to others.  Indicate your total time committed and the frequency for each service you list  (Additional pages may be attached if needed.)

	Review our “Helpful Hints: Best Practices & Important Information” document to find samples 	and examples for this section.

Service	Total Time Committed

e.g. 120 hours	Frequency and Length of Service 

e.g. 2 days a week for 6 months	
      	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	       	          	
     	          	          	
     	          	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	     	          	
     	          	          	
     	          	          	
     	          	          	
     	          	          	
     	          	          	
     	          	          	
     	          	          	
     	          	          	
STUDENT PROFILE (continued)

3.	Honors/Awards – List awards received for school activities or from outside organizations.  Describe each honor/award and explain the importance of it.    This section should reflect honors/awards received during the 9th, 10th & 11th grades.  Do not abbreviate the name of the organization granting the award.  Awards received multiple times should be listed together.  (Additional pages may be attached if needed.)

	Review our “Helpful Hints: Best Practices & Important Information” document to find samples 	and examples for this section.

Code:  I-International, N-National, S-State, R-Regional, D-District, C-Community, or HS-High 	School.  

Code

	Honor/Award

	Grade

	Individual or 
Group Honor	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	
          	          	          	          	

2019 Writing Entry Prompts

In 500 words or fewer, please respond to one of the prompts below. The primary goal of the writing entry is to allow the committee to learn more about you as a person—what matters to you, what makes you interesting, and/or what makes you stand out.  Whichever topic you choose, be sure that your writing entry gives the reader a chance to learn more about you.  The diction and tone of your response should be appropriate for the topic you select. Your entry must be typed and double-spaced. Failure to follow directions will result in a loss of points. You may type and attach your writing entry as a separate document. 

Please clearly designate on your writing entry page which prompt you have selected to answer.  Place the prompt number, without the prompt question, at the top of your writing entry page.

Review our “Helpful Hints: Best Practices & Important Information” document to find scoring guidelines and a rubric for this section.

Writing Entry Prompt Number 1: 
What is one issue that you care deeply about in your community that, if explored with others, you could make a difference to the future of that issue?  

Writing Entry Prompt Number 2: 
The logo of the Governor’s Scholars Program is a tree with a trunk in the form of a torch.  Write an essay about how the tree can work metaphorically to explain your sense of self.  HINT: Do not spend most of your essay recounting the physical aspect of the tree, but rather what is most important to us is what the image reveals about you. 

Writing Entry Prompt Number 3:  
Aside from all of your awards, activities, and accomplishments, what makes you interesting? Tell us about a part of yourself that would surprise us and that reaches beyond your résumé.

Writing Entry Prompt Number 4:  
Explain why a particular Protagonist, Hero—male or female—of a novel, film, poem, or other work of art, has been especially important to you.  Be sure to emphasize what the character reveals about you. Hint:  Do not spend most of your essay summarizing the novel, film, poem, or work of art; what’s most important to us is what the work reveals about you.

Writing Entry Prompt Number 5:  
Describe an experience where you learned something, whether it was a skill, an idea, a life lesson, or something else. 

Writing Entry Prompt Number 6:  
What question changed how you understand the world?  Explain how a particular 	question—and its answer, answers, or lack of answer—made a difference in your thinking.

WRITING ENTRY (Continued)