EMBRACE Scholarship Application Form

EMBRACE Scholarship Application Form

Clinical Mental Health Counseling (CMHC) and Social Work students only
This scholarship opportunity is made possible thanks to the kind and generous support of Molina Healthcare, in partnership with EMBRACE ALL LATINO VOICES. Together, we are committed to investing in the next generation of Clinical Mental Health Counseling and Social Work professionals dedicated to serving diverse and multilingual communities.

Click here to read the application guidelines: https://www.embracealllatinovoices.org/post/embrace-all-latino-voices-graduate-scholarship-program
Application
Name*

First NameLast Name
Email (use your University email address)*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Information
Name of High School Attended
Address

Street Address

Street Address Line 2

CityState / Province / Country

Postal / Zip Code
Year Graduated
Academic awards and/or honors you received in High School
Are you a member of any organization at your university? Please provide information
Are you a member of any organization OUTSIDE your university? Please provide information
If you have volunteer hours at any organization, church, community association, sports groups, etc. Please attach the signed letter(s) of volunteer work.

If you have more than one letter, please combine them in ONE pdf file.
Upload here your volunteer hours

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Please fill out the fields below:
Name of your university*
Area of study*

Clinical Mental HealthSocial WorkOther
Expected graduation month/year*
Please provide any academic achievements or awards you have received in College (if there are any)

Parental Information
Name of Mother or Guardian*

First NameLast Name
Mother's Job/Position
Address of Mother*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Father

First NameLast Name
Father's Job/Position
Address of Father (if not the same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I CERTIFY THAT ALL STATEMENTS OR INFORMATION I HAVE PROVIDED ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY DELIBERATE MISREPRESENTATION FOUND IN THIS APPLICATION MAY BE CAUSE FOR THE APPROVAL OF THIS APPLICATION AND MAY PROHIBIT ME FROM APPLYING AGAIN IN THE FUTURE.
Applicant's Signature*

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Name of Applicant*

First NameLast Name
Date Signed by Applicant*

MonthDayYear
Date
Should be Empty:

EMBRACE Scholarship Application Form

Application

Educational Information

Parental Information

Financial and General Information

Resume, personal statement letter, and student documentation

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