Amherst College: Replenishing Democracy

Phone: (413) 542-5805
FAX: (413) 542-5837

Summer Institute on Civic Engagement and Political Activism
June 9-23, 2007

Apply Online

Please read these directions carefully before filling out the application below, and make sure all pertinent questions are answered completely and accurately. Applications will not be considered unless all required materials are submitted by the deadline.

Your application materials must include:
  1. The completed application form
  2. Official academic transcripts of complete undergraduate school record to date
  3. Letters of recommendation: one faculty member who can evaluate your academic performance and an optional evaluation from someone who has supervised your extracurricular activities or is knowledgeable about your leadership skills. Recommendation forms are provided below.
  4. Personal statement, not to exceed the equivalent of two double-spaced typewritten pages, in which you describe a social problem or issue of concern and the role of political activism in addressing it.

You may find it easier to write your personal statement in advance and cut and paste it into the appropriate box in this form.

1. Last/Family Name:     
    First and Middle Names:

2. Date of Birth (month/day/year)    Gender:

3. Current Mailing Address

Until when is this mailing address correct? (month/day/year)

Current telephone number:      

E-mail address:

Cell phone number:

4. Home Mailing Address (permanent)

Permanent telephone number:

5. Citizenship: US citizen      US Permanent Resident visa
     citizen of

6. Ethnic background (optional):

7. How did you find out about Replenishing Democracy?

8. Post graduate education or plans:

9. Undergraduate Education: List all institutions attended (current and most recent first)

College/University Location Major GPA Dates attended

10. Anticipated date of graduation (month/day/year):

11. High School Education

Secondary/High School Location Dates attended

12. Academic Honors/Awards

13. Extracurricular Work Experience, Volunteer and Community Activities/Awards

14. Additional comments or information that did not fit in form fields

Personal Statement

Please describe a social problem or issue of concern and the role of political activism in addressing it. This should not exceed the equivalent of two double-spaced typewritten pages. We suggest that you compose it outside this application and then cut and paste the text into the personal statement box.

Recommenders

A.  First Recommender

Last/Family Name:     

First and Middle Names:

Position and Department

Mailing Address:

 E-mail:

Telephone:

B.   Second Recommender

Last/Family Name:     

First and Middle Names:

Position and Department

Mailing Address:

E-mail:

Telephone:

Please indicate the city, state, and country where you expect to be traveling from to attend the Institute:

I understand that if any information provided on this application proves to be false, it may prevent my selection and/or participation in the Summer Institute.

Name:

Date: