Pafford Medical Services Healthcare Scholarship Application

Pafford Medical Services

$500 Healthcare Scholarship Application Form
Please read before applying to ensure all application requirements are met prior to submitting this form. Deadline: April 3, 2026.

Name

First NameLast Name
Name of High School
High School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of School Counselor
County
Date of Application Submission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Primary Email
example@example.com
Secondary Email (Must fill out if above is school email. If your secondary email is the same as above, please confirm your primary email here.)
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Applicant's Mailing Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Expected Graduation Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cumulative GPA
Which University do you anticipate attending?
What State is the University located?
Choose one of the listed questions and describe your answer in an essay format, 500 words or less. A) Why are you choosing the healthcare field? B) How has someone in healthcare inspired you? C) What does community service mean to you, and what measures have you taken to impact your community?
Essay (750 words or less)

List your extracurricular activities, including sports, clubs, and organizations:

Personal and/or Academic Reference (atleast 1 is needed)

Rows	Name	Position	Contact Information (email or phone number)
Reference
Reference

Please review our scholarship rules and regulations that must be followed should you be awarded this scholarship in order to obtain your funds.
Applicant's Declaration

I hereby certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in the disqualification of my application, revocation of any awarded benefits, and potential legal action by Pafford Medical Services, Inc. if deemed necessary.
Applicant's Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: