2011 Carter Mario Injury Lawyers Arrive Alive Scholarship

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					                                 2011 Carter Mario Injury Lawyers
                                    “Arrive Alive” Scholarship
                                            Application

Please mail your application to Carter Mario Injury Lawyers, 158 Cherry Street, Milford, CT 06460, postmarked
no later than March 25, 2011, along with a copy of your high school transcript and your essay or video
presentation.

 * All personal information provided will be kept strictly confidential.* * Mandatory attendance is required of all
          winners to attend a scholarship presentation the week of May 2, 2011. Time to be announced.*

Applicant Information
                                                                  (Please attach a recent photo
Name __________________________________                                 of yourself here)

High School _____________________________

Home Mailing Address ____________________

City ____________ State_____ Zip __________

Home Phone # ___________________________

E-mail Address __________________________

Date of Birth ____________________________

Gender: ____ Male ____ Female

GPA: ____ SAT: ____ Math ____ Writing ____ Critical Reading ____

Maternal Information

Mother’s Full Name _____________________________

Mother’s Address _______________________________

Mother’s Home Phone # __________________________

Mother’s E-mail Address _________________________

Mother’s Occupation ____________________________
Paternal Information

Father’s Full Name _______________________________

Father’s Address _________________________________

Father’s Home Phone # ____________________________

Father’s E-Mail Address ___________________________

Father’s Occupation _______________________________

Activities and Community Involvement
Please list all athletic activities you have participated in during your high school career.

Sports:

Letters won:

Special Awards or Achievements:

School Activities
Please list all school activities in which you have participated during your high school career including clubs,
student government, and other school organized events.

Activities:

Positions of Leadership:

Special Awards or Achievements:

Community and Religious Involvement
Please list any religious and community activities in which you have been involved during your high school
career.

Activities:

Positions of Leadership:

Special Awards or Achievements:

Employment
Please list any employment you held during your high school career.

Employer:

Position Held:

Brief Job Description:

Dates of Employment:
Academic and Professional Pursuits
What field of study do you plan to pursue?

Please list all colleges and /or universities you have applied to or plan to apply. Include Name, City, State, and
Status of Application for each.

Presentation Content & Instructions Written essay, video, or graphic presentation is acceptable.
(Essay: approximately 500 words. Video: 2-5 minutes. Please submit with application.)

Cell Phone Distracted Driving, (defined as when motorists use a cell phone to call or text while behind the wheel),
is currently playing a major role on Connecticut’s highways. With technology advancing at an astronomical rate,
cell phones have become the right hand of today’s youth. The National Safety Council has estimated that 1
million people are chatting behind the wheel at any given moment. It is now fair to say that the combination of
texting and driving is becoming as lethal as getting behind the wheel intoxicated.

Base your Arrive Alive submission on the following fictional scenario:

Carter Mario is asking for your help to prepare a presentation to your graduating class on the dangers of
distracted driving that will make them not want to get behind the wheel with a cell phone. You may submit a
written essay, a video, a graphic presentation, etc. Choose whatever format best supports your thoughts and
ideas. Think outside the box. What you create could positively impact Connecticut’s response to Distracted
Driving, help to shape future legal actions, and most importantly save lives.

All submissions will be judged by Carter Mario and his staff of attorneys. The top 10 winners will each be
awarded a $1,000.00 scholarship check made out to the college they will be attending.

Honor Pledge

I completed this application on (date) ______________. The answers above are true to the best of my knowledge.
The essay response is my own work.

Signature of Applicant ________________________________

Carter Mario Injury Lawyers thanks you for making a difference in our community. Good luck to all
our applicants!

				
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