Online Application Form - Second Chance Scholarship Foundation

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Second Chance Scholarship Foundation Inc. is an organization devoted to providing assistance to youth who have come in conflict with the law or are at-risk for such and who show strong promise and potential for completing post-secondary school education.

Name of Applicant *

Email *

Telephone Number

Name of referring Agency / Organization

Name of individual completing referral

Address of referring Agency / organization

Telephone Number of individual completing referral

E-mail address of individual completing referral

Date Referral completed

How could Second Chance assist this youth in achieving his/her goal of completing post secondary school education?

Books

Approximate Cost

Tuition

Approximate Cost

Transportation (Please specify & Approximate Cost)

Academic:

a) Post-secondary institution to be attended & Field of study in which youth interested

b) Level of education completed

c) Currently enrolled in post secondary school studies

d) If currently enrolled in post secondary school studies, provide brief summary of such; e.g. attending full time; study by correspondence; commencement date of program; length of academic program; year of program in which youth is enrolled)

e) If not currently enrolled please provide details as to such; (e.g. commencement date of program; attendance will be full time/part time; study by correspondence; length of academic program; year of program in which youth will be enrolled)

f) Date funding / assistance required

g) In your opinion does this youth have the capacity and motivation to complete the post secondary school academic program in which they are interested? On what basis is this opinion formed?

h) Secondary school grades

Poor
Average
Good
Excellent

Current Status Of Custodial Disposition:

Youth currently in a secure custody facility

Youth currently in an open custody facility

Youth currently on

Probation
Community Supervision

General Non-Identifying Information:

Level of motivation/ commitment to completing post secondary school education

Poor
Average
Good
Excellent

Youth’s level of positive community support

	Poor	Average	Good	Excellent
Mother	PoorMother Poor	AverageMother Average	GoodMother Good	ExcellentMother Excellent
Father	PoorFather Poor	AverageFather Average	GoodFather Good	ExcellentFather Excellent
Step Mother	PoorStep Mother Poor	AverageStep Mother Average	GoodStep Mother Good	ExcellentStep Mother Excellent
Step Father	PoorStep Father Poor	AverageStep Father Average	GoodStep Father Good	ExcellentStep Father Excellent
Siblings	PoorSiblings Poor	AverageSiblings Average	GoodSiblings Good	ExcellentSiblings Excellent
Girlfriend / boyfriend	PoorGirlfriend / boyfriend Poor	AverageGirlfriend / boyfriend Average	GoodGirlfriend / boyfriend Good	ExcellentGirlfriend / boyfriend Excellent
Friends	PoorFriends Poor	AverageFriends Average	GoodFriends Good	ExcellentFriends Excellent
Children’s Aid Society	PoorChildren’s Aid Society Poor	AverageChildren’s Aid Society Average	GoodChildren’s Aid Society Good	ExcellentChildren’s Aid Society Excellent

Please include general comments/observations on this youth’s support in the community including quality of relationships with individuals providing encouragement/support.

Level Of Responsibility:

Positive behaviour displayed while on current custodial disposition.

	Poor	Average	Good	Excellent
Reporting to Probation Officer	PoorReporting to Probation Officer Poor	AverageReporting to Probation Officer Average	GoodReporting to Probation Officer Good	ExcellentReporting to Probation Officer Excellent
Behaviour while in custody	PoorBehaviour while in custody Poor	AverageBehaviour while in custody Average	GoodBehaviour while in custody Good	ExcellentBehaviour while in custody Excellent
Participation in rehabilitation groups	PoorParticipation in rehabilitation groups Poor	AverageParticipation in rehabilitation groups Average	GoodParticipation in rehabilitation groups Good	ExcellentParticipation in rehabilitation groups Excellent
Participation in individual counseling	PoorParticipation in individual counseling Poor	AverageParticipation in individual counseling Average	GoodParticipation in individual counseling Good	ExcellentParticipation in individual counseling Excellent
Maturity levels	PoorMaturity levels Poor	AverageMaturity levels Average	GoodMaturity levels Good	ExcellentMaturity levels Excellent
Social skills	PoorSocial skills Poor	AverageSocial skills Average	GoodSocial skills Good	ExcellentSocial skills Excellent
Rate the youth’s ability to quickly and effectively recover from unexpected challenges, disappointments, short term failures, breakdown of significant personal relationships.	PoorRate the youth’s ability to quickly and effectively recover from unexpected challenges, disappointments, short term failures, breakdown of significant personal relationships. Poor	AverageRate the youth’s ability to quickly and effectively recover from unexpected challenges, disappointments, short term failures, breakdown of significant personal relationships. Average	GoodRate the youth’s ability to quickly and effectively recover from unexpected challenges, disappointments, short term failures, breakdown of significant personal relationships. Good	ExcellentRate the youth’s ability to quickly and effectively recover from unexpected challenges, disappointments, short term failures, breakdown of significant personal relationships. Excellent
Responsibility assumed for actions (e.g. does applicant consistently offer excuses or blame others/circumstances for irresponsible behaviours).	PoorResponsibility assumed for actions (e.g. does applicant consistently offer excuses or blame others/circumstances for irresponsible behaviours). Poor	AverageResponsibility assumed for actions (e.g. does applicant consistently offer excuses or blame others/circumstances for irresponsible behaviours). Average	GoodResponsibility assumed for actions (e.g. does applicant consistently offer excuses or blame others/circumstances for irresponsible behaviours). Good	ExcellentResponsibility assumed for actions (e.g. does applicant consistently offer excuses or blame others/circumstances for irresponsible behaviours). Excellent

Any other comments you wish to offer which would assist the Second Chance Scholarship Foundation in their consideration of this referral:

Applicant’s Comments

*Please have youth complete “Applicant’s Comments” form below and attach.

Second Chance Scholarship Foundation Inc. recognizes that this record may contain information about a young person which is defined by and subject to the Youth Criminal Justice Act. As such, Second Chance Scholarship Foundation Inc. recognizes that all use of information about the young person is subject to publication, use and access restrictions set out in the Act to protect the privacy of the young person.

1. Why do you wish to pursue post secondary school education?

2. Why are you interested in the field of study you have chosen to pursue?

3. Why do you think you should receive assistance from the Second Chance Scholarship Foundation?

4. What does completion of Post Secondary School studies mean for you?

5. Why is successful completion of post secondary school studies important?

6. What have you found most difficult in your post secondary school studies to date?

7. How does your family, friends, girlfriend/boyfriend, spouse feel about you attending post secondary school?

8. Briefly describe where you see yourself in 5 years? In 20 years?

For any inquiries pertaining to this application, please contact Rick Gosling at rickgosling@breakfastclubs.ca. Please submit any additonal questions or information below:

Attach File

Click or drag a file to this area to upload.