AGS 2019 | Student General Information Form - Page 1 of 4
2019 ARKANSAS GOVERNOR’S SCHOOL
STUDENT GENERAL INFORMATION FORM
(NO ATTACHMENTS ALLOWED)
Student: It is your responsibility to make sure that complete and accurate information is supplied on this form and all Area I
application forms.
For clarity and legibility, applications must be typed. Handwritten applications will not be considered.
NAME GENDER
(Last) (First) (Middle)
RACE (optional) Asian Black Hispanic American Indian/Alaska Native Hawaiian/Pacific Islander White Two or more races
NAME (Preferred) E-MAIL ADDRESS ______________________________
HOME MAILING ADDRESS TELEPHONE ( )________________
(Street) (City) (Zip Code)
HIGH SCHOOL NAME TELEPHONE ( )__________________
PRINCIPAL’S NAME__________________________________________E-MAIL ADDRESS________________________________
SCHOOL’S MAILING ADDRESS________________________________________________________________________________
(Street) (City) (Zip Code)
SCHOOL DISTRICT NAME COUNTY____________________________________
1. Based on your ability and interest, indicate your choices for nomination placing a number 1 or 2 beside your choice in order
of preference. An Area I Application Form must be completed for EACH area you choose.
(A separate audition must be submitted for each of the areas marked with an “*”. Ask your counselor for audition instructions.)
_____*Choral Music: Indicate the part you sing: ___________________________
URL for YouTube video audition: ____________________________________________________
_____*Drama: URL for YouTube video audition: ____________________________________________________
_____*Instrumental Music Indicate the instrument you play: ___________________________
URL for YouTube video audition: ____________________________________________________
_____*Visual Arts URL for my private YouTube video audition: ___________________________________________
_____ English/Language Arts
_____Mathematics
_____Natural Science
_____Social Science
_____Cybersecurity Specialty Program
AGS 2019 | Student General Information Form - Page 2 of 4
2. List any significant achievements, awards, or accomplishments in the past two years. You cannot exceed 2,000 characters.
3. List any school/community projects in which you have participated that demonstrate your commitment to a task. You cannot
exceed 2,000 Characters.
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4. Student Essay: Must be typed in the space provided only. You cannot exceed 4500 characters. Attachments will not be
considered.
Oliver Wendell Holmes said, “Man’s mind, once stretched by a new idea, never regains its original dimensions.”
Using your own writer’s “voice,” illustrate to the selection committee how a new idea has stretched your mind. In several well-written
paragraphs, specifically describe the idea, its source, and the lasting impact of this new idea in your life. A successful essay will enable
the selection committee to see and hear what makes you unique. The committee will be looking for creativity, originality, honesty,
clarity of expression, evidence of integrity and sincerity, tenacity of purpose, imagination, and an ability to organize one’s thoughts.
AGS 2019 | Student General Information Form - Page 4 of 4
5. Understanding/Consent Form (To be read and signed by parent/guardian and student nominee)
This section assumes that parents/guardians and nominees fully understand their responsibilities if nominees are selected to attend
Arkansas Governor’s School. Signatures of both nominees and parents/guardians are required.
I understand the 2019 Arkansas Governor’s School Leave Policy as is presented below and consent to these terms.
2019 Arkansas Governor’s School Leave Policy
The Governors School is state funded, highly competitive, and interested in fostering a very strong sense of community among its
participants. Therefore, it is believed to be inappropriate for students who have accepted a place at AGS to take temporary leaves from
the program. Time away from the program has an undesired effect on student participation, both for the individual and for the Governor’s
School community at large. We know that students will have many quality opportunities during the summer. Although we hope that
students invited to attend AGS will accept our invitation to attend for the full four weeks, we understand that other choices are available
and difficult decisions must be made. For students desiring to take advantage of other opportunities that coincide with AGS, students
should decline the AGS invitation which will allow another student to be invited to benefit from the entire program.
Temporary leaves will be granted for certain situations and only these situations. Requests for special leaves of absence must be made in
writing at least one (1) week in advance and include explicit justification for the leave. A leave may be granted for the following situations:
unplanned personal or family emergencies
weddings of immediate family members
extremely important events of major personal, regional, or national significance
Leaves will not be granted if:
proper paperwork has not been filled out and submitted according to the one week timeline
the leave is for a period of more than two class days
the leave is during the first three days or the last three days of the program
the student has already been granted a leave
I understand that students must commit to attend the entire length of the program, July 7 to August 3, 2019.
I certify that I have read and understand the above information and consent to its terms and that the information in this application is
correct to the best of my knowledge. I hereby consent to my son’s/daughter’s nomination to the Arkansas Governor’s School and for the
school officials to report my child’s achievement and aptitude test scores. I also waive my right to review any comments/information
supplied.
Parent/Guardian Signature
Address, City, State, Zip Code
I certify that I have read and understood the above information and consent to its terms. I certify that the information in this application
is correct to the best of my knowledge, and that the essay I have submitted is mine. I understand I will be expected to complete assignments
both in and outside the classroom. I understand that all school data related to my nomination are available to the Student Selection
Committee and I waive my right to review any comments/information supplied. I hereby submit my name for nomination to the
Arkansas Governor’s School and agree that if accepted, I will attend for the entire program, July 7 to August 3, 2019.
Student Nominee’s Signature
Date