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France-Anne Sweeny “Making a Difference” Graduate Award
Application Form
First Name
Middle Name
Last Name
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Home Address:
City:
Province:
______________________________________________________________________________
Postal Code:
Home Telephone Number:
_____________________________________________________________________________
E-mail Address:
Twitter Account:
___________________________________________________________________________
Name of School: _______________________________
Grade: _______________
Please Attach:
1. Candidate Statement:
List three(3) tasks you have completed during your high school years, that help to tell us
who you are and how you have “Made a Difference”. (Use between 90 and 130 words per
task).
Where do you see yourself in 10 years and how will that be affected by your desire to make
the world a better place? (Use between 100 and 150 words)
2. A current secondary transcript or Credit Counseling Summary of your marks.
I certify that the information provided on this application form and in the accompanying documentation is true, accurate and complete.
Applicant's Signature:
Date:
Applications are to be submitted by Friday, May 1st, 2015 to:
Paul Sweeny: Swenco Limited, 560 Conestoga Road, Waterloo, Ontario, N2L 4E3
T: 519-884-7400 F: 519-884-8821 E: psweeny@swencolimited.com
Release Form
Permission to use Photographs and Personal Information related to the
France-Anne Sweeny “Making a Difference” Awards
Student: ____________________________________
School: _____________________________________
I grant the France-Anne Sweeny “Making a Difference” Fund and its representatives, the right
to take photographs of me and use the personal information included in my Award application,
in connection with the Awards identified above. I authorize the France-Anne Sweeny “Making a
Difference” Fund to use and publish the same in print and/or electronically.
I agree that the France-Anne Sweeny “Making a Difference” Fund may use such photographs
and information with or without my name and for any lawful purpose, including for example
such purposes as publicity, illustration, advertising and Web content.
I have read and understand the above:
Signature: _____________________________________________________________________
Printed Name: __________________________________________________________________
Date: _________________________________________________________________________
Signature, parent or guardian: _____________________________________________________
(If under age 18)