Application form for MathsGenius Leadership Institute's academy program for 2014. For 3 weeks, you will live on the MathsGenius Leadership Institute campus and study with the MGLI exceptional faculty and guest speakers from various industries and leading institutions of higher learning.

1. 566 Nupen Crescent, Halfway Gardens, Midrand, 1685, South Africa
Phone: +27 785 858 937
Email: info@mathsgenius.co.za
Nurturing quantitative leaders for development
WELCOME TO MATHSGENIUS ACADEMY 2014
Dear Applicant,
Thank you for your interest in MathsGenius Academy (MGA). By completing this application you will be on your journey to
being a superb mathematician and problem solver. The form helps us to get to know you, your past, present and future
aspirations.
Prior to completing this application, we encourage you to learn as much as possible about MathsGenius Academy. Read our
brochure, ask us questions, or visit our website: www.mathsgenius.co.za. Think about the part you see yourself playing in
solving your community’s problems through innovative problem solving. If you believe MathsGenius Academy is the place
for you to gain insight into mathematics and problem solving then take the next step and apply!
Thank you for choosing MathsGenius to assist you in unleashing the mathematical genius in you, do not stop striving for
higher ideals. This is the first step.
Kind regards,
MathsGenius Academy
APPLICATION INSTRUCTIONS
The MathsGenius Academy application form consists of eight parts, all of which are compulsory. We cannot accept
applications that are incomplete.
A. Application data form
B. Application academic information
C. School reports and national exam results from the past year (attachments)
D. Family information
E. Short answer questions
F. Essay questions
G. Extra-Curricular Activities
H. Certification page
Submitting Your Application:
All completed applications MUST be received by the MathsGenius Academy Admissions office 10 weeks prior to intended
date of attendance.
Please complete the following 7 pages and attach updated copies of your school reports and your national exam results. Be
sure to write your name and contact information on each page of your application. You can submit your application to the
MathsGenius Academy Admissions Office through:
 Email: info@mathsgenius.co.za (Recommended method)
 Fax: ****************
 Via certified courier to MathsGenius Academy, 566 Nupen Crescent, Halfway Gardens, Midrand, South Africa.
Please list “MGA Admissions Administrator” as the receiver and write +27785858937 for the receiver’s phone
number.
Confirmation of Receipt:
An email/sms confirmation will be sent to you after we receive your application. Please contact the Admissions Office only if
you do not receive a confirmation message within one week of submission. Please keep a full set of copies of all
application materials in case your application is lost in transit. MathsGenius Academy will not be held accountable
for lost or missing applications.

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3. MathsGenius Academy Application 2014 Page 2
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Day Month Year
Country code
Country
Country(If Different)
Country code
Day Month Year
YearMonth
Country codeCountry code
A. APPLICATION DATA FORM
Please type or write clearly in CAPITAL LETTERS only!
PERSONAL INFORMATION
Please enter your name and all information as it appears on official documents, such as your identification card, birth certificate, or
passport.
Surname (Family Name):
First Names (Given Names):
Gender: F M Nationality: Birth Date: / /
Country:
Country of Citizenship:
Do you have a passport? Yes No Passport #:
If you have a passport, please attach a copy of it to this application.
Passport Issued by (Country): Expires on: / /
Your Email Address:
Your Secondary Email Address:
Mobile Phone: (+ ) Other Phone: (+ )
Permanent Physical Address:
Address During School Year:
B. APPLICANT ACADEMIC INFORMATION
Current School: Language of Instruction:
Physical Address:
Postal Address:
Current Grade Level/Form/Year: Expected Date of Graduation: /
Name of Principal or Head of School:
Principal’s contact information:
Office Phone (required): (+ ) Fax (optional): (+ )
Mobile Phone (required): (+ ) Email (optional):
School Type (mark all that apply): Government/Public Independent/Private Religious Boarding
School Year Begins: (month) and Ends: (month)
List all other secondary schools, summer schools, or academic programs you have attended:
C. ATTACH A COPY OF ALL SCHOOL REPORTS FROM THE PAST YEAR (2013)
(DO NOT send original transcripts. MGA will not return original documents to you.)
Have you ever been found responsible for a disciplinary violation at any secondary school you have attended,
whether related to academic or behavioural misconduct, which resulted in your probation, suspension, removal,
dismissal, or expulsion from school? YES NO
How did you first learn about MathsGenius Academy? (Please mark only one)
Information session / presentation (please specify location):
Teacher, principal or counsellor (please list name):
Friend, parent, guardian or relative (please specify and list name):
Your own search on the Internet
Other, e.g. newspaper, magazine, radio (please specify):
Facebook or other social media (please specify):

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Country codeCountry code
Country codeCountry code
Have you applied to MathsGenius Academy before: Yes No
Applicant Name: Phone/Email:
D. FAMILY INFORMATION
Please list the adults who currently have legal rights and responsibilities toward you, such as your parents or guardians. Please ensure
that this information is correct.
Section 1: Parents or Guardians
Parent/Guardian #1 Surname: Gender: F M
First Names (Given Names):
Relation to You: Occupation:
Highest Level of Education /Degree Attained:
Mobile Phone: (+ ) Other Phone: (+ )
Email:
Physical Address:
Parent/Guardian #1 possesses legal guardianship over you? Yes No
Applicant Living with: Parent(s) Relative(s) Other
Parent/Guardian #2 Surname: Gender: F M
First Names (Given Names):
Relation to You: Occupation:
Highest Level of Education /Degree Attained:
Mobile Phone: (+ ) Other Phone: (+ )
Email:
Physical Address:
Parent/Guardian #2 possesses legal guardianship over you? Yes No
Applicant living with: Parent(s) Relative(s) Other
Are your parent(s)/guardian(s) married? Yes No
Are your parent(s)/guardian(s) BOTH (if applicable) present and able to sign a letter to consent to your travel to
South Africa should you be admitted to MathsGenius Academy? Yes No
If no, please explain why they are unable to sign:
Primary language spoken at home: Other Languages:
OPTIONAL: Your Race/Ethnicity: Your Religious Affiliation:
OPTIONAL: Your mother’s Race/Ethnicity: Your mother’s Religious Affiliation:
OPTIONAL: Your father’s Race/Ethnicity: Your father’s Religious Affiliation:
Section 2: Siblings: Please list the Names, Level of Education, Genders and Ages of any brothers/sisters you
have, even if they don’t live in your household:
Full Name Gender
(M/F)
Age Highest level of education
/ degree attained
Phone (if your sibling
is 18 years or older)
Email (if your sibling is
18 years or older)

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Applicant Name: Phone/Email:
E. SHORT ANSWER QUESTIONS
Note: Please do not exceed the space provided.
1. What excites you most about MathsGenius Academy?
2. What are you passionate about and why?
(i) How long have you held this passion?
(ii) How do you demonstrate this passion in your daily life?

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Applicant Name: Phone/Email:
F. ESSAY QUESTIONS
3. In this section we would like you to describe a time when you identified a need in your community
(such as your family, school, village, or town) and took action:
(i) What need did you identify?
(ii) How did you address this need?
(iii) What difficulties did you encounter?
(iv) What was the outcome?

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Applicant Name: Phone/Email:
ESSAY QUESTIONS
4. Whom do you admire as a leader and why?
5. Imagine yourself in the next few years. What is your vision for your country/Africa? What do you
see as your contribution to the betterment of your country/Africa?

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Applicant Name: Phone/Email:
G. ACTIVITIES
7. Please list up to five of the most important activities in each category (in order of importance to
you) that you have participated in during the past three years.
School and Community Service:
Activity Hours
per week
Role Number of years
participated
e.g. Student Government 3 Treasurer 1
1.
2.
3.
4.
5.
Employment/Entrepreneurial Enterprises:
Activity Hours
per week
Role Number of years
participated
1.
2.
3.
4.
5.
Competitions/Conferences/Special Programs:
Activity Hours
per week
Years participated role Number of years
participated
1.
2.
3.
4.
5.
Artistic/Musical:
Activity Hours
per week
Role Number of years
participated
1.
2.
3.
4.
5.
Athletics:
Activity Hours
per week
Role Number of years
participated
1.
2.
3.
4.

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5.
H. CERTIFICATION PAGE
TO BE COMPLETED BY THE APPLICANT:
I, , hereby certify that all information
contained in this application is truthfully and accurately presented and my work alone.
Signature: Date:
TO BE COMPLETED BY THE APPLICANT’S PARENT/GUARDIAN:
I, , hereby give permission for
to apply to MathsGenius Academy, a world-class,
mathematics and leadership school in South Africa.
Signature: Date:
Phone Number or Email:
Full name
Full name
Applicant Name