WALTON

INTERNATIONAL
SCHOLARSHIP
PROGRAM

_____________
APPLICATION FORM

_____________
Harding University
Dr. Nicky Boyd, Director
Searcy, AR 72149-0001
479-279-4551
Fax: 479-279-4109

John Brown University

Mr. Ron Johnson, Director
Siloam Springs, AR 72761
479-524-7236
Fax: 479-524-7463

University of the Ozarks

Dr. Rickey J. Casey, Director
Clarksville, AR 72830-2880
479-979-1232
Fax: 479-979-1355

E-mail: [email protected]

E-mail: [email protected]

E-mail: [email protected]

Walton International Scholarship Program

Application Form
Part A: Personal Data
1. Full Name_______________________________________________________________
Surname/Family Name

First

Middle

2. Current mailing address:____________________________________________________

Number and Street

_____________________________________________________________________________________________________________
City/Town
State/Province
Country
__________________________________________Telephone:(______)_______________________________________________
Postal Code
Country Code
City Code

Email address_______________________________________
3. Citizenship:__________________________ Date of Birth:________________________
City of Birth:_________________________ Country of Birth:_____________________
Passport Number:______________________ Issued at:___________________________
Sex: Male Female

Marital Status: Single Married Divorced

4. Religious Affiliation/Preference:_____________________________________________
5. Have you ever visited or lived in the U.S.? If yes, how long? Please explain:________
_______________________________________________________________________
6. Have you ever had or do you currently have a U.S. Passport or Visa to enter the U.S.?
Yes No If yes, please explain:_________________________________________
_______________________________________________________________________
7. Health: Excellent Good Fair Poor Please complete medical section of application form.

Part B: Parental Data

8. Name of: Parent Legal Guardian Other Relative
___________________________________________________________________________
Surname/Family Name

First

______________________________________________________________________________________________________________
Number and Street
City/Town
______________________________________________________________________________________________________________
State/Province
Country
______________________________________________________________________________________________________________
Postal Code
Telephone Number

Fathers Occupation__________________________________________________________
Mothers Occupation_________________________________________________________
Estimated Total Family Income_________________________________________________
Religious Affiliation__________________________________________________________
9. Names and addresses of any relatives or friends living in the United States:
Name
Address
Relationship
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Part C: Academic Data
10. List in chronological order, from high school/secondary to the present, the schools and
Universities you have attended.
School
Location
Dates
Degree/Diploma
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Have you taken the required TOEFL (Test of English as a Foreign Language)? Yes No
If yes, what was your score:_________________
Indicate your level of English proficiency:

Spoken Excellent Good Average Poor

Written Excellent Good Average Poor

Name of person who referred you to the scholarship program:_________________________

___________________________________________________________________________

Information About Your Program Plans

1. Academic major you intend to pursue:_________________________________________
2. Intended vocation:_________________________________________________________
Please include the following required information.
1. Complete academic records (copies of transcript and most recent diploma).
2. A personal essay, in English, describing your family background, your personal and
professional goals, and plans upon graduation.
3. Reference letters from a teacher, clergy and employer, if applicable.
4. Documentation of annual family income (in U.S. dollars).
5. Recent photo.
6. Complete the Medical and Immunization section of application form.
Please read carefully
The three Universities are Christian institutions. Because of this we are interested
in the personal as well as academic education of each of our students. Therefore,
we offer opportunities for students to experience personal growth. Some of the
opportunities are mandatory. These include: 1) attending chapel services, and 2)
enrolling in Bible courses.
While all students are not required to be Christians in order to enroll at the
Universities, all students are required to respect the environment, which is an
important part of our Christian lifestyle. In particular, students are prohibited
from smoking, drinking, using or possessing drugs and using profane language
while on campus as well as any other regulations as outlined in the student
handbook of the Universities.

I certify that to the best of my knowledge this information I have given is accurate and
correct. I understand that falsification of any information in this application is
grounds for dismissal from the program. Furthermore, I have read and do understand
the above statement and, if admitted, will comply with all the rules and regulations set
forth by the administrators of the Walton International Scholarship Program and the
University granting me the scholarship. Finally, I will return to my home county when I
complete my education at this University.

Signature:_______________________________________Date:_______________________

Medical and Immunization Record

The health history and immunization record is for use by the Student Health Services Office of
John Brown University, Harding University, and University of the Ozarks. The contents of this
record are confidential and will not be released without your consent.
Name________________________________________________Phone____________________
Surname/Family Name

First

Middle

Current mailing address:__________________________________________________________

Number and Street
__________________________________________________________________________________________________________________
City/Town
State/Province
Country

Birthdate____________________________________ Social Security #:

_____________________________________________

Month/Day/Year

Family Physician:
Name_________________________________
(______)_____________________

Telephone

Address_______________________________________________________________________
Number and Street
__________________________________________________________________________________________________________________
City/Town
State/Province
Country

Emergency Notification:
Name______________________________________ Relationship________________________
Telephone: Day (______)_________________ Evening (______)__________________
Name______________________________________ Relationship________________________
Telephone: Day (______)_________________ Evening (______)__________________
Name______________________________________ Relationship________________________
Telephone: Day (______)_________________ Evening (______)__________________
Insurance Company_____________________________ Policy #_________________________

Personal History:
Information on this form is for use by the University Health-Counseling staff. The contents are
confidential and will not be released without your knowledge and consent.
Have you ever had:
Asthma
Allergies:
Medication
Food
Plant
Insect Bites
Other
Heart Murmur/Problem
Kidney Stones/Disease
Convulsions/Seizures
Visual Problems
Hearing Loss
Arthritis
Malaria
Diabetes
Hypoglycemia
Thyroid Disease
Anemia
Anorexia/Bulimia
Hepatitis
Tuberculosis
Rheumatic Fever
Bleeding Disorder
HIV Positive
Surgery
Headaches/Migraines
Emotional Disturbance
Epilepsy
Other:______________

No

Yes

Yes

(currently)

(previously)

Comments/Explanation

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_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Do you have a medical disability? Yes No If yes, please specify:__________________

______________________________________________________________________________
Are you under a physicians care now?
Yes
No
If yes, please
specify:______________
______________________________________________________________________________
Allergy Shots Laboratory Monitoring Other:_________________________________
List any prescription medications taken on a frequent or regular basis: (name, dosage, frequency)
______________________________________________________________________________
______________________________________________________________________________
Do you use syringes for self medication? Yes No
(If yes, you must sign a Safe Needle Disposal form at the Student Health Services Office upon arrival)

Is there anything the Health Services Office should know in order to give you better health care?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Immunization Status
___ To be verified by Physician or Health Care Official. All students must have a documented
history of immunizations verified by a physician. We will also accept immunization records
from your doctors office, the Health Department, or school records, but must include specific
dates for each dose.
Date Immunized

Date Immunized

(month/day/year)

(month/day/year)

Tetanus (within 10 years)

Polio (last in series of 4)
*Rubeola (measles)
*Rubella (German or 30day measles)
*MMR (Measles, Mumps, Rubeola)
At this time, the American Medical Association recommends 2 MMR doses by the time of adulthood.
*Arkansas state law requires that if you were born after January 1, 1957 you must have received both vaccines after your first
birthday. If you are unable to do this prior to enrollment, you may receive it during registration at no charge. Persons
seeking a religious or medical exemption to the Immunization requirements of Arkansas institutions of higher education
may obtain an application form from the Student Health Services Offices. Any exemption status must be completed before
classes begin.

Are there any existing health conditions that might need medical attention or monitoring such as
special diets, medication levels, etc.? _____________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

_____________________________________________________________
Health Care Professional
(Signature of doctor, nurse, nurse practitioner, P.A., or D.O. is REQUIRED)

Consent for Treatment: Consent is hereby given for treatment in University of the Ozarks Student Health Services Office by
duly licensed medical personnel or by a health care provider of choice in the community for routine health care, assessment,
diagnosis, treatment, and if necessary, hospitalization. No guarantee has been made to me as to the results to be obtained by
treatment given to me.
It is understood that the University will contact the next of kin as soon as possible in case of an emergency or serious illness.
Signed: ________________________________________________

Date: ____________________________________________

Parent or Guardian: _______________________________________

Date: ____________________________________________

(if student is under 18 years of age)