High School Scholarship Application Form

The Dietmar Gann, MD Scholarship

This scholarship was created in honor of Dr. Dietmar Gann, a local innovative cardiologist. His life was a testament to the power of compassion and care. The tremendous impact he made on this world, and the incredible life he lived, have left a legacy that will continue to shine bright. This scholarship is exclusively offered to Walden Grove High School students, where his grandchildren are alumni and some currently enrolled. The Dietmar Gann, MD Scholarship for $1,000 is for applicants interested in pursuing a degree in Healthcare.
BASIC INFORMATION

If awarded, must attend scholarship night to receive check and award.
Walden Grove High School Scholarship Application (2025-2026)

The information provided on this form will be used by the High School Scholarship Committee to select recipients for scholarships. It is important that you give complete details concerning your college/career plans, activities and financial information.
Student ID:*
Student's Full / Legal Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Phone Number*

Area CodePhone Number
Student E-mail*
Student Birth Date

MonthDayYear
Gender
Academics
Academic GPA*
Class Rank
Schools to which you are applying
School 1
School 2
School 3
School 4
School 5
School 6
Will Live
Major(s) You Are Considering

In order of preference, list the major(s) you are considering (Very important for scholarship eligibility).
Major 1
Major 2
Major 3
Estimated cost
School Type & Estimated Cost

REFERENCES:

Please list one educator and at least one community person who would recommend you for a scholarship. Please do not list the person who completes a scholarship recommendation for you.
Reference 1 Name (Position,Phone Number)
Reference 2 Name (Position,Phone Number)

SCHOOL / COMMUNITY ACTIVITIES / WORK / EXPERIENCE/SPORTS/AWARDS/ETC:

List name of club, etc. and years of participation. If you volunteered, list the name of organization and the number of hours, weeks and years that you volunteered. If you worked, list the company, hours per week and length of time. Attach an additional sheet or resume if necessary.
School Activities / Offices Held 1: (not sports)
School Activities / Offices Held 2: (not sports)
School Activities / Offices Held 3: (not sports)
School Activities / Offices Held 3: (not sports)
Community Service / Volunteer Activities 1 (outside of school)
Community Service / Volunteer Activities 2 (outside of school)
Community Service / Volunteer Activities 3 (outside of school)
Sports Participation 1
Sports Participation 2
Sports Participation 3
Will you be participating in a sport(s) this year?

YesNo
What Sport?
Travel Experience or Unusual Experiences (study abroad, etc.)
School / Community Awards and Honors 1 (no matter how small) CSF, GSE, National Honor Society, Girl/Boy Scouts, 4-H, Governor’s Scholar, etc.
School / Community Awards and Honors 2
School / Community Awards and Honors 3
EMPLOYMENT 1: List past and present work and length of time employed.
EMPLOYMENT 2: List past and present work and length of time employed.
EMPLOYMENT 3: List past and present work and length of time employed.

Needs-based Scholoarships Parent Financial Information

If you want your student to be considered for need-based scholarships, you will need to make available a copy of the first page of your most resent tax return and you must complete the information requested below. All information supplied by you will be treated as confidential. If you chose not to submit any financial information, your student will not be considered for need-based scholarships. Most donors require a financial statement. If your financial circumstances change after you have submitted this form, please feel free to contact us. Complete this entire page if you want your student to be considered for need-based scholarships.
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Complete only the items marked with an asterisk (*) if you do not want your student to be considered for need-based scholarships. Stepparent information may replace Mother or Father's information: Please report earnings for the parent/stepparent who the student has lived with most of the time (over 50%) in the past twelve months. If the student lives with both parents equally then provide answers about the parent/stepparent who provides the most financial support.
Father/Stepfather/Guardian Name
Father/Stepfather Employer and Occupation
Mother/Stepmother/Guardian Name
Mother/Stepmother Employer and Occupation:
Number of dependents in home:
First generation to attend college?

YesNo
Father/Stepfather Annual Income :
Mother/Stepmother Annual Income :
Other income that can be used for educational purposes (inheritance, college funds, etc)-do not include home equity, IRA's or other retirement accounts (optional):
Other Income Type 1:
Other Income Amount 1:
Other Income Type 2:
Other Income Amount 2:
Please explain any unusual circumstances such as, child-support ending, emergency expenses, medical bills, seasonal work, unemployment, etc.

SCHOLARSHIP RECEIVED TO DATE 1
AMOUNT 1
SCHOLARSHIP RECEIVED TO DATE 2
AMOUNT 2
STUDENT STATEMENT:*
Submission Time

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

The Dietmar Gann, MD Scholarship

BASIC INFORMATION

Walden Grove High School Scholarship Application (2025-2026)

Academics

Schools to which you are applying

Major(s) You Are Considering

Estimated cost

PERSONAL DATA:

REFERENCES:

SCHOOL / COMMUNITY ACTIVITIES / WORK / EXPERIENCE/SPORTS/AWARDS/ETC:

Needs-based Scholoarships Parent Financial Information

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