INSTRUCTIONS: Application must be submitted by 4 pm on Friday, November 13, 2020. Electronic applications submission may be sent to
the subject line of applicants first and last name and USSYP application. Applications submitted via mail should be sent to the address above and made to
attention of Curriculum and Instruction c/o Elizabeth Hiler. Application must have original signatures. Please review eligibility requirements prior to applying.
NAME OF STUDENT (Last, First, Middle) Mr. Ms. HOME TELEPHONE (Include Area Code) CELL TELEPHONE (Include Area Code)
HOME ADDRESS (Street, City, State, Zip Code) COUNTY OF RESIDENCE
E-MAIL ADDRESS OF STUDENT (Required)
NAME OF PARENT(S)/GUARDIAN
CURRENT ELECTED OFFICE(S)*
*To be eligible, a candidate must be a United States citizen or permanent legal resident of the United States of America at time of application and serve in one of the
following leadership roles for the entire 2019 or the 2020 school year:
a. Student body president, vice-president, secretary or treasurer
b. Class president, vice-president, secretary or treasurer
c. Student council representative
d. National Honor Society officer member or officer member in a discipline-based National Honor Society
e. Student representative elected or appointed (appointed by a panel, commission or board) to a local, district, regional or state-level civic, service and/or educational
organization approved by the state selection administrator.
APPLICANT'S CURRENT YEAR IN SCHOOL
DATE OF BIRTH (mm/dd/yyyy) HIGH SCHOOL GRADE POINT AVERAGE
NAME OF HIGH SCHOOL NAME OF HIGH SCHOOL PRINCIPAL
SCHOOL ADDRESS (Street, City, State, Zip Code) SCHOOL TELEPHONE (Include Area Code) E-MAIL ADDRESS OF PRINCIPAL
SCHOOL DISTRICT NAME AND NUMBER NAME OF SCHOOL DISTRICT SUPERINTENDENT
NAME OF REGIONAL SUPERINTENDENT OF SCHOOLS
(Not applicable for Chicago Public School District 299 students)
E-MAIL ADDRESS OF SCHOOL DISTRICT SUPERINTENDENT
NAME OF YOUR STATE SENATOR AND DISTRICT NUMBER IN THE ILLINOIS
NAME OF YOUR STATE REPRESENTATIVE AND DISTRICT NUMBER IN THE
ILLINOIS GENERAL ASSEMBLY
Please attach to this application a typed narrative (not to exceed two pages) describing:
1. Your involvement in student government and community service;
2. Achievements, especially leadership experiences, that would support your selection as a candidate;
3. Ways in which your participation in this year's William Randolph Hearst Foundation United States Senate Youth Program will enhance your interest in and
understanding of this country's political and governmental processes; and
I affirm that I am the sole author of the attached essay and meet the eligibility requirements of the William Randolph Hearst Scholarship.
Date Original Signature of Student
I hereby certify that the above named student is a junior or senior in good standing, holds the elected ofce(s) identied above and has presented
accurate GPA information. I also certify that the student's parent or legal guardian resides in Illinois and that this district does not traverse state lines.
Date Original Signature of Principal
100 North First Street, N-253
Springeld, Illinois 62777-0001
THE UNITED STATES SENATE YOUTH PROGRAM –
WILLIAM RANDOLPH HEARST SCHOLARSHIP
SCHOOL YEAR 2020-2021
Completed original applications must be received in the
Springfield office by 4:00 p.m. on Friday, November 13, 20
Form can be completed online and printed.
CURRICULUM AND INSTRUCTION
ISBE 42-60 (10/20)
Use your "Mouse" or "Tab" key to move through the fields and check boxes. After completing last field, save document to hard drive to make future updates or click print button.