APPLICATION FORM - COHORT THREE ACADEMIC YEAR - 2016/2017 MAKERERE Attach two copies of recent passport photograph Makerere University, in partnership with The MasterCard Foundation is implementing a Scholars Program that targets academically talented yet economically disadvantaged youth of Africa to access quality undergraduate education. Only students admitted to Makerere University main campus will be considered for this scholarship. This application form is free of charge. Applicants are advised to read the application guidelines before filling in the form. After completing the form, submit to Senate Building, Level 4, Room 401 or send through email address msgender@gender.mak.ac.ug / info@mcfsp.mak.ac.ug Only short listed candidates will be contacted to appear for interview. Cases of impersonation, falsification of documents, giving false/incomplete information whenever discovered will lead to automatic cancellation and/or prosecution in the Courts of Law of Uganda. The deadline for submission is 27 th May, 2016. To be filled by applicant (Incomplete applications will not be considered) Section A. Personal Information of Applicant (As per UACE registration) A1 A2 A3 Surname Names Date of Birth (did/mm/yyyy) (Attach a photocopy of a birth certificate ) A4 Sex Male Female A5 Place of Birth: District Country of Birth Country of Citizenship A6 Native Speaker/Language A7 Current Contact Address Village District of residence Sub-county Country A8 Name the nearest main road from the district town to your home/residence Attach a sketch map of how one gets to your home/residence or draw it on page 12 A9 A10 Give a distinctive feature to your home District of Origin if different from district of residence B: Contact Information B1 B2 B3 B4 Applicant s telephone number Parent/Guardian s telephone number Mother s telephone no Permanent email address: 1
B5 Facebook email address:2 B6 B7 B8 B9 B10 B11 B12 School Contact Information School email address School telephone number(s) contact person likely to know how to reach the applicant in the future Relationship to applicant: Country of residence: Contact email address: Contact Phone(s) Section C. Academic Information Examination C1 UACE/its equivalent (Attach a photocopy result slip/certificate and Identity Card) Year of undertaking this exam School/Institution /District Overall score or grade point Was the school Public or Private C2 C3 C3 UCE (attach a photocopy of a result slip/certificate) PLE (attach a photocopy of result slip/certificate) Amount of fees paid at each level per year Advanced level, secondary school Ordinary secondary school C4 Indicate the subjects offered at A level and the grades obtained in each 1. 2. Subjects Grade points Grades Obtained 3. 4. 2
5. General Paper Total Section D: Socioeconomic Background D1 Status of Mother Alive Deceased Unknown Attach copies of death certificates if applicable D2 Status of Father Alive Deceased Unknown D3 Do you live at an orphanage or other care institution? Yes No D4 d) Siblings Who is the head of Household (Tick applicable) D5 Specify D8 D9 Head of Household #1's highest level of education completed: Head of Household #1's occupation (Tick) a) Mother b) Father c) Guardian e) relatives f) Guardian not related to scholar g) Self h) D6 Gender of Head D7 Age of Household Primary Secondary Tertiary TVET No formal Education Armed Forces occupation Clerical Support workers Crafts and Related Trades workers Elementary occupations (laborers, street workers, street vendors etc.) Managers Plant and machine operators Professionals Service and sales workers Skilled Agricultural workers Subsistence farmers, fishers and gatherers Technicians and associated professionals Don t Know D10 s (Specify) D11. Occupational Status of head of household #1: Employee - Full-Time Employment Employee - Part-Time Employment Self-Employed - With Employees Self-Employed - Without Employees 3
Retired - With Pension Retired - Without Pension Not Employed D12. Head of Household #1's income Per Year D13 List sources of income: Activity Income D14 D15 Head of Household #2's highest level of education completed: Head of Household #2's occupation (Tick appropriately) Primary Secondary Tertiary TVET No formal Education Armed Forces occupation Clerical Support workers Crafts and Related Trades workers Elementary occupations (laborers, street workers, street vendors etc.) Managers Plant and machine operators Professionals Service and sales workers Skilled Agricultural workers Subsistence farmers, fishers and gatherers Technicians and associated professionals Don t Know E 15 s (Specify) D16 Please provide compelling evidence that you are socially and economically disadvantaged and that you qualify for the scholarship. Show evidence 4
Head of household #2: Specify if not same as household #1 D17. Occupational Status of head of household #2: Employee - Full-Time Employment Employee - Part-Time Employment Self-Employed - With Employees Self-Employed - Without Employees Retired - With Pension Retired - Without Pension Not Employed D18. Head of Household #2's income Per Year D19. Which household members does the applicant live with? (check all that apply): Mother Father Guardian(s) Sibling(s) (Indicate no. of siblings) Relative(s) Friend(s) Self Please explain 'other' household member:.. D20. Which sources take care of the majority of your household expenses? (check all that apply): Parent(s) Guardian(s) Self Sibling(s) Guardian(s) not related to scholar Community member(s) Government 5
Relative(s) D21. Please specify:.. D22. Who paid for previous schooling? (check all that apply): Employer Guardian(s) Guardian(s) not related to scholar Relative(s) Parent(s) Scholarship (Attach recommendation from the sponsor) Self Sibling(s) Sponsor(s) If, please state who paid fees.. D23. State whether you have a passport. Yes No D24. If you have a passport, what was the purpose of your travel? D25. Estimated household expenses at time of application (e.g. Food costs, electricity bills, rent costs): (Per month) D26. Number of people living in household including the applicant: D27. Number of dependent children living in household including the applicant: D28. Number of dependent children living in household who don t go to school excluding applicant: D29. State whether your household has livestock? Yes No D30. List the livestock and state the numbers D31. Does the household have electricity? Yes No 6
D32 Does the household have a title deed? Yes No D33. State the type of Toilet Flash and Pour VIP latrine Covered Pit latrine Uncovered Pit Latrine Composting toilet No facility /bush /field Ecosan D34.Toilet shared with others Yes No D35. Is their running water in the household Yes No D36. Type of Roofing material D37. Type of house (permanent or semi-permanent) D38. Type of Floor D39. Number of Rooms in the house D40. List the household assets i.e. mobile phone, TV, Radio, Bicycle, Car, Refrigerator, etc. E: Section E: Leadership Experience E1 E2 E3 Describe previously held leadership position, activities, or experiences: (i.e. positions where the scholar has guided or led a group of people, a project, or a cause): Awards and Honors received: (i.e., secondary school citizenship award; president's medal for outstanding leadership, etc. Are you good at public speaking? E4. Participation in extracurricular activities: Sports Religious Groups School Clubs Community services Local organizations Peer-to-peer groups E5 Explain E6. If you have been a member of a team, club, organization, or association, specify your role: Member 7
Chair Vice Chair Secretary Founder E7 Explain. E8. If you have previous work experience, please provide a short explanation of this experience.... Section F: Community Service Experience F1 F2 F3 Describe your previous voluntary experience Describe the activities you undertook that demonstrated commitment to the community, spirit of service, and/or 'give back/go back' qualities: Describe your aspirations for social change and how you plan to achieve social change through your career F4. Which sectors do you plan to impact through your social change aspirations? Agriculture Skilled Trades Small Business / Entrepreneurial Social & Humanitarian services Health & Medical Information Technology Public Service / Government Religious Education 8
If please explain. F5. Which sectors do you plan to impact through your career aspirations? Agriculture Skilled Trades Small Business / Entrepreneurial Social & Humanitarian services Health & Medical Information Technology Public Service / Government Religious Education If please explain. F6 Do you have any form of disability? Yes No F7 If yes, what form of disability? F8 How did you hear about the Scholars Program: Radio Newspaper Poster MCF Staff Former School Friend/word of mouth, specify.. F9 What career do you plan to pursue? (I.e. Doctor, Humanitarian Relief Worker, Entrepreneur, Teacher, etc.) I declare that all the information provided here is true and accurate to the best of my knowledge, and I have read and understood the note to applicants below. Applicant: Signature and Date: / /2016 Name: Parent/guardian: Signature and Date: / /2016 Name: 9
Please note: The decision of The MasterCard Foundation Scholars Program Selection Committee at Makerere University for award is final. SECTION G: TO BE COMPLETED BY THE HEAD TEACHER OF YOUR FORMER ADVANCED LEVEL SECONDARY SCHOOL Please provide your assessment (to the best of your knowledge) about the applicant on: Academic ability Excellent (among the top 10) Very good (top 20) Good (top 35) Fair (top 50) Financial ability: Rich Middle-class Economically Disadvantaged Highly economically disadvantaged Name and Signature of Head Teacher (with date and stamp) Name: Signature Stamp Mobile No. Date: / / SECTION H: TO BE COMPLETED BY LOCAL COUNCIL 1 OFFICIALS FROM THE DISTRICT OF RESIDENCE VERIFICATION OF THE APPLICATION LC I Chairperson a) Surname name(s) b) Village (LCI) Parish Sub-County District c) Does the applicant reside in this village? Yes/No If yes, for how long d) For how long have you known the applicant? e) What is the applicants district of origin? f) How many biological children are in her/his family? How many are independent or working? g) What does/ did the father do to earn a living? h) What does/did the mother do to earn a living? i) Who was paying the applicants fees at secondary school level? j) Any other important information? 10
k) RECOMMENDATION : Strongly Recommended Recommended Not Recommended State the reason(s) for your recommendation DECLARATION I, the undersigned, hereby declare that I have carefully checked and verified the particulars stated above and certify that they are true and accurate. Name Signature Stamp and Date Please Turn Over 11
Draw a sketch map to your residential home here. 12