Johnston Ziegler Safrit Scholarship Application – Keep Until Next Year

Explore the History

The purpose of the scholarship is to identify and support local high school seniors who are leaving a mark on their community. It also showcases and celebrates positive adolescent role models and reinforces Teen Health Connection’s mission. Through this scholarship, which is part of the Teen Health Connection Legacy Fund, Teen Health Connection is investing in future leaders, changemakers, and advocates.

By recognizing their leadership, advocacy, and service in the community, Teen Health Connection supports their ongoing academic success and encourages them to continue their impactful work.

To apply for the Johnston Ziegler Safrit Youth Leadership Scholarship, complete the application below. 

APPLICANT'S INFORMATION

Applicant Name
Mailing Address

GUARDIAN'S INFORMATION

Mailing Address (Guardian)

Media and Photography Release

I hereby grant Teen Health Connection permission to use, re-use, exhibit, distribute, or publish my and/or my child’s testimonials, images, artwork, portraits, pictures or videos for any Teen Health Connection purpose including but not limited to Teen Health Connection illustrations, art, videos, promotional materials, editorials, advertising, publications, websites or web content, all without any compensation.  I understand that any images, videos, or artwork may be used at exhibits and may identify me and/or my minor child.  I relinquish any right that I may have to inspect, examine, or approve any completed product or products or any written or electronic copy or other printed matter that may be used in conjunction with any of the foregoing.  I understand and agree that all materials containing the images or artwork of me and/or of my minor child shall become the property of Teen Health Connection.

I hereby release, discharge and agree to forever hold harmless Teen Health Connection, its legal representatives or assigns, and all persons or entities functioning under its permission or authority from all and any claims, demands or causes of action ensuing from or in connection with the use or publication of any of the foregoing including without limitation any claims for libel or invasion of privacy.  This authorization and release shall inure to the benefit of the legal representatives, licensees, and assigns of Teen Health Connection and shall be binding upon me and upon my estate, my heirs, and my legal representatives.

I have read and fully understand the content, meaning, and impact of the foregoing and represent that I am the individual named below.  I agree that I am over the age of majority or that I am the parent or legal guardian of the minor child named below, am over the age of majority, and hereby consent to the foregoing on behalf of such minor child named below.

Applicants Name
Parent/Guardian Name:
Clear Signature

ESSAY REQUIREMENTS

The Johnston Ziegler Safrit Youth Leadership Scholarship is built on the pillars of leadership, advocacy, and service, all of which were exemplified by Dr. John Johnston, Barbara Ziegler, and Libby Safrit. How have you demonstrated leadership, service, and advocacy? Please include the following in your response:

  1. What was the community issue (problem) that you addressed?
  2. Describe how you demonstrated leadership, advocacy, and service.
  3. What was the impact of your efforts?
  4. How did this experience impact you?

Responses should be a minimum of 1,000 words. There is no maximum.

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.
Save your application to complete later.