Wayne HealthCare Foundation Scholarship Application
Please visit WayneHealthCare.org/Foundation
Last Name
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First Name
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Email Address
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Phone Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
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High School
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Accredited College University
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Street Address of School Currently Attending
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Course of Study
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HS Graduation Date
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College Graduation Date (Expected)
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Month
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Day
Year
Date
High School GPA - Grade Point Average
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College GPA (If Applicable) - Grade Point Average
Photo (jpg/png): Please attach a current picture of yourself.
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Video (MOV/MP4): Either a MOV or MP4 File Formats can be uploaded within this form. If you run into any issues, please email your video to WayneHealthFoundation@gmail.com. A short video is required, that includes an introduction and your passion for your future in medicine or a healthcare-related field.
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Essay (pdf/docx): Please attach an essay of 500 words or less that describes your educational and career goals, including the reason for your career choice.
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High School Transcript (pdf): If your transcript contains your social security number, please black out/remove before uploading.
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College Transcript (if applicable) (pdf): If your transcript contains your social security number, please black out/remove before uploading.
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Letter of Recommendation (1/3) (pdf/docx): Please attach letter of recommendation on letterhead.
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Letter of Recommendation (2/3) (pdf/docx): Please attach letter of recommendation on letterhead.
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Letter of Recommendation (3/3) (pdf/docx): Please attach letter of recommendation on letterhead.
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Financial Aid (pdf/docx): Include a summary page with your potential financial aid, scholarships (awarded and pending), and plan for paying for courses of study.
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Resume of Extracurricular Activities: Please upload a resume of activities, volunteerism, or other notable accomplishments you would like us to be aware of.
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Other (pdf):
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AUTHORIZATION OF VERIFICATION:I certify that the information provided is correct to the best of my knowledge, and I authorize a representative of the Wayne HealthCare Foundation Scholarship Committee to contact the High School and/or College listed above to verify this information. If awarded, I agree to allow Wayne HealthCare Foundation to use my picture/likeness in any public relations and release liability.
Date
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