Scholarship Program

Scholarship Program
Section I. Personal Information

To be completed by Student
Student's Date of Birth

MonthDayYear
Date
Student's Name

First NameLast Name
Sex
Student's Permanent Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Parent/Guardian 1 Name
Parent/Guardian 2 Name
List the institutions where the applicant has applied followed by their acceptance status (Yes, No, Pending):
Intended Profession/Career
Section II.
Upload your official high school transcript for grades 9-12:

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Section III. - Personal Essay

Type a one page essay following these instructions.
Write an essay that explains how your planned career in the dental/medical field will contribute to society. The essay must be typed, double-spaced on one-side of one-page, with your name and address in a single line across the top of the page. Essays longer than one page/one-sided will be disqualified.
Please upload your essay

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Section IV. - Activity Section

To be completed by Student
NAME OF CLUB/ACTIVITY SPONSORED BY HIGH SCHOOL (Honor Society, Yearbook, Newspaper, etc.)
SCHOOL YEAR 9th, 10th, 11th, 12th
MAJOR OFFICE HELD List Here
MOST SIGNIFICANT CONTRIBUTION List Here
NAME OF EXTRACURRICULAR ACTIVITY SPONSORED BY HIGH SCHOOL (Band, Choir, Sports, Cheerleading, etc.)
SCHOOL YEAR 9th, 10th, 11th, 12th
HONOR/SList Here
MOST SIGNIFICANT CONTRIBUTION List Here
WORK EXPERIENCEList Here
SCHOOL YEAR 9th, 10th, 11th, 12th
SUMMER EMPLOYERList Here
SCHOOL YEAR9th, 10th, 11th, 12th
COMMUNITY ACTIVITY/VOLUNTEERList Organization Here
SCHOOL YEAR 9th, 10th, 11th, 12th
SUMMER EMPLOYERList Here
SCHOOL YEAR9th, 10th, 11th, 12th
Should be Empty:

Scholarship Program

Section I. Personal Information

Section II.

Section III. - Personal Essay

Section IV. - Activity Section