Construction Safety Scholarship Application - Governors Industrial Safety and Health Advisory Board

Parental Consent
I agree to the release of this information for the Governor's Industrial Safety and Health Advisory Board's consideration of this application. I further authorize the release of my child's name and image (photographic or video), if selected to receive the scholarship, to the Board for educational and promotional purposes.
- Yes, I consent to the release of my child's information
- No, I do not consent to the release my child's information
Applicant Information
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Are you 18 or older?*
- Yes
- No

Additional Infomation
School and Community Activities
Please provide a summary description of any extracurricular activities which you have been involved with, your responsibilities as well as the duration of your participation.
Honors and Awards
Please list all honors and/or awards which you have received.
Click the + to add additional entries.
Offices and Positions of Leadership
Please list all of the offices and/or positions of leadership which you have held.
Click the + to add additional entries.

Employment History
List Jobs Held
Include at least 5 years worth of employment or as many positions as you have held in the last 5 years or upload a resume as an attachment.
Click the + to add additional entries.
Position Responsibilities From To
Resume
Attach resume
Accepted file types: doc, docx, pdf.

Applicant Essay
Please provide 300 – 500 word essay outlining how you intend to further your occupational safety and health education and what you plan to do in the future to increase workplace safety & health.
You may type your essay below or upload as an file attachment.
Type Essay
Essay Upload
Accepted formats: doc | docx | pdf
Accepted file types: doc, docs, pdf, txt.

References
The application must include references from the a Counselor or Advisor, a Teacher or Professor, and one from another person in your Community. Providing their name and email will allow them to see your name and the scholarship name but no other information.
Counselor/Advisor Reference Name
First Last
Email
Personal Note to Counselor/Advisor
Please help me apply for the Construction Safety Scholarship by providing a reference.
Advisor/Counselor Reference
Teacher/Professor/Employer Reference Name*
First Last
Email*
Personal Note to Teacher/Professor/Employer*
Please help me apply for the Construction Safety Scholarship by providing a reference.
Teacher/Professor Reference
Community Reference Name*
First Last
Email*
Personal Note to Community Reference
Please help me apply for the Construction Safety Scholarship by providing a reference.
Community Reference*

CERTIFICATION AND RELEASE AUTHORIZATION*
I certify that the information contained in this application is true, complete and accurate; I authorize release of any of this information to confirm and/or verify this application. I further authorize the release of my name and image (photographic or video) to the scholarship grantor for educational and promotional purposes.
I certify this submission is accurate and consent to release of name and image.
Parental Consent
Since you are under 18, you must provide the name and email address of a parent or guardian to provide consent. They will be able to view your application and submit their consent.
Parent Name
First Last
Parent Email
Email
This field is for validation purposes and should be left unchanged.

Applicant Information

Position	Responsibilities	From	To