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2015 Coca-Cola MENA Scholarship Program

Application Completion Checklist


(Must be completed in English)

Candidate Name
(Full Name as it appears
in passport)
Name of University
(Currently enrolled in)
Year of Study
Concentration Area of
Study
E-Mail Address
Home Address
Age
Gender
City and Country
Occupation

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)

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

* All applications must be received via e-mail by February 6th, 2015.


Any applications received after this time will not be considered.
Please e-mail applications to:
MENAscholarships@coca-cola.com
2015 Coca-Cola MENA Scholarship Program
Application Form
NAME:
________________________________________________________________________________________
(First)

(Middle)

(Last name as indicated on passport)

CONTACT INFORMATION
Mailing
Address
(if different
from home
address)

Cell
Phone
Work
Phone

Home
Phone

PERSONAL DATA
Gender
Date of Birth
(Month, Day,
Year)
Country of
permanent legal
residence
Dual Citizenship?
Year of Study
(check one)

Male

Female
Place of
Birth
(City,
Country
Country of
citizenship

Yes

No

1st Year

If yes, indicate
country

2nd year

3rd Year

** YOU MUST PROVIDE AN ELECTRONIC COPY OF THE PICTURE/INFORMATION PAGE OF PASSPORT.

MILITARY STATUS (Men Only)


Check one

Completed
N/A

Exempt

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

Non-Exempt

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

ENGLISH LANGUAGE PROFICIENCY


Number of years of
Where Studied:
English Study:
Reading proficiency (check one) Excellent

Good

Fair

Writing proficiency (check one)

Excellent

Good

Fair

Speaking proficiency (check


one)

Excellent

Good

Fair

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

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/YY
From:
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 Dates
MM/YY MM/YY
From:

To:

From:

To:

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

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

US
Government
Program?
Y/N

From:

To:

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

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.

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

2015 Coca-Cola MENA Scholarship Program


Faculty Recommendation Form
Thank you for taking the time to complete this recommendation form. This form gives us an idea of the
students 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.
Students motivation and maturity (please rank and explain):

Students ability to handle ambiguity (please rank and explain):

Students 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):

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

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 History

All 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 ____________

Do you smoke? Yes

Weight ________

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

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

pressure, pregnancy, etc.)


__________________________________________________________________________
__________________________________________________________________________

I hereby agree that the information provided above is true to my knowledge.


________________________________________________________________
PARTICIPANT SIGNATURE

DATE

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

ASSUMPTION OF RISK AND RELEASE FROM LIABILITY


WHEREAS, 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: _____________________________

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

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

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

PHOTO AND VIDEO RELEASE


Example Name ______________________________________________________________
Participant

Name

FIRST

Mohamed
FIRST NAME Raafat
MIDDLE NAME

NAME

MIDDLE NAME

LAST

El Habiby
LAST NAME (AS INDICATED ON PASSPORT)

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
Preferred
(If publicizing
differentorthan
given
Mohamed
Raafat
university
or forName
promoting,
explaining
the surname)
school or its activities.
This grant
includes, without limitation, the right to
publish such images in the universitys student newspaper, alumni/ae magazine, on the universitys Web site, and public
relations/promotional materials, such as marketing and admissions publications, advertisements, fund-raising materials and any
other
university-related
These
images may appear
Hometown
(City,publication.
Country)
Alexandria,
Egyptin 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
without University
compensation to me (the
undersigned). All electronic or non-electronic
Academic Institution
Ainare
Shams
Major/Concentration
negatives, positives, and prints are owned by the university.
Engineering
I hereby acknowledge that I have read and understand the terms of this release.

Personal
Interests or Hobbies (list up to four)
____________________________________________

_____________________

PARTICIPANT SIGNATURE

Swimming
Hiking

DATE

Reading
Football

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

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
Extra Extra Large

Small

Medium

Large

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

Extra Large

Bradford Woods--Indiana Universitys Outdoor Center


Participation 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 (______) __________________
Physicians 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 Release


During 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.
______________________________________________________

___________________________

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

Participant Signature (Legal guardians signature if participant is under 18)

Date

Global Release
Program Name: Global Business Institute
Program Dates: June, 2015
Indiana 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 Release


I, 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.
___________________________________________________________
Signature (Legal guardians signature if participant is under 18)
Date

_________________________

Participant

Photographic Release
I 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.
____________________________________________________________
Signature (Legal guardians signature if participant is under 18)
Date

_________________________

2015 Coca-Cola MENA Scholarship Program

Classified - Unclassified

Participant