2025 PPMD Scholarship Registration Form

Scholarship Registration Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Student E-mail*
example@example.com
College/University Enrolled: *
Health Care Degree Program: *
Previous Semester GPA:*
Expected Matriculation Date: *

MonthDayYear
Date
Please Choose the Answer that Applies to School Status*

Full TimePart Time
Instructions

After completing this application form, please provide your responses to the Scholarship Application Questions below. Each response should be no more than 500 words.
a. Summarize health initiatives or activities that you have been involved in that directly impacted the Pinellas Park Community (or other communities you have been involved in).*
b. If you can propose one health initiative that would make an impact in Pinellas Park, what would it be? What resources could be put together to launch this initiative? *
c. Describe your community service achievements in Pinellas Park and/or other communities. List the agency, organization, or groups you have worked with; describe the projects or events; and indicate the number of volunteer hours served.*
d. Describe how this scholarship would help you to meet your future educational goals. *
Part 2 To demonstrate eligibility, please include supporting documentation of your educational achievements and community service experience.

Required documentation:Resume/curriculum vitae, Enrollment verification
Resume/Curriculum Vitae *

Each response should be no more than 500 words.
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Enrollment verification *

Each response should be no more than 500 words.
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Optional documentation (at least one of these three is required)

Transcripts, Acceptance letter, Documentation of financial need.
Transcripts

Please be sure to upload any other relevant material
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Acceptance letter

Please be sure to upload any other relevant material
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Documentation of financial need

Please be sure to upload any other relevant material
Cancelof
Final Part

Submit completed application form, typed or printed responses, and supporting documentation.
By singing below I am acknowledging I have completed the application process and that I have read the scholarship criteria and based on my education and local community service (Pinellas Park or other communities I have been involved in) achievements - I am eligible to apply. I am also authorizing If selected as a scholarship recipient, the Pinellas Park Medical District to make a press release and/or post a photo and written notice on the Chamber/PPMD websites and social media announcing my receipt of this scholarship award.
Signature*

Clear
Today's Date*

MonthDayYear
Date Application Submitted
The Pinellas Park/Gateway Chamber is Proud to support this Scholorship by utilizing Our 501-C(3). The Pinellas Park Foundation
Should be Empty:

Scholarship Registration Form

Instructions

Optional documentation (at least one of these three is required)

Final Part