EmailMe Form - Catherine Coleman Foundation Application

Application Information
First Name *
Last Name *
Address *

Street Address City State / Province / Region Postal / Zip Code
Phone Number *
Email *
Gender *
Male
Female
Non-binary
Date of Birth *
Education
High School *
Address *

Street Address City State / Province / Region Postal / Zip Code
High School years of attendance:
From *
To *
Did you graduate? *
Yes
No
Diploma
Food Information
Are you vegan/vegetarian? *
Yes
No
Do you have any food allergies? *
Yes
No
If yes, please list food allergies below *
Medical Information
Please select any medical condition which may recur or be a factor in medical treatment. We want to ensure the accessibility and safety of all participants.
Allergy
Physical Disability
Seizures
Medicine Reactions
Blackouts
Disease of any Kind
Heart or Lung Problems
Other
None
Please explain any medical conditions checked above:
Are you currently taking medications? (if so, please list.)
Creative Writing Selection
Please select your first and second choices. *

1st Choice

2nd Choice
Submit The Following
I. PERSONAL STATEMENT: In a one-two page essay, tell us why you want to attend the Initiative and what you hope to accomplish. You may want to discuss your writing sample, a writer (or writers) you admire, a book or film that has had an impact on your life, and any creative writing skills you want to develop. This will allow us to get to know a bit more about you.
Upload Your Personal Statement *
II. WRITING SAMPLE: Please submit a writing sample of your work. Your sample should consist of no more than 10 pages of fiction, poetry, or drama/screenwriting, or a combination of genres. Fiction may consist of a short story, in whole or in part, or part of a longer piece (novel or novella). Poetry may be a collection of various pieces, or samples of longer pieces provided that the submission is coherent. Those interested in Screenwriting may submit a scene or film synopsis. The writing sample should be typed and doubles-spaced (poems do not need to be double-spaced, and multiple poems can appear on a page if possible. Please submit as a Word or PDF.
Upload Your Writing Sample *
Release and Signature
Jackson State University and all partner associates reserve the right to use a student’s name, likeness, voice, or creative works in brochures, advertising, the Internet, and any other promotional or educational purpose.
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Student Printed Name *
Student Signature *
Clear
Parent or Legal Guardian Name *
Parent or Legal Guardian Signature *
Clear

1st Choice
2nd Choice

Application Information

Education

High School years of attendance:

Food Information

Medical Information

Creative Writing Selection

Submit The Following

Release and Signature