Welsford and Mildred Clark Medical Memorial Scholarship

WELSFORD & MILDRED CLARK MEDICAL MEMORIAL SCHOLARSHIP FUND
GENERAL INFORMATION AND ELIGIBILITY REQUIREMENTS:

Scholarships are granted upon application to those students who seem best to satisfy the requirements of the Welsford and Mildred Clark Medical Memorial Trust Fund within the limits of the funds available. Review of applications and the selection of recipients have been assigned by the Trust Fund to the Waterbury Medical Association.

The eligibility requirements for this scholarship award are:
1.You must, at any time during the twelve years preceding your application, have maintained continuous residence in Connecticut for a period of at least five years. Please explain how you meet this criteria.

2. M.D & D.O. medical student applicants must apply the year BEFORE graduation. The Scholarship will be applied to the last year of medical school.

3. Enrollment in a medical school accredited by the LCME, COCA and/or the World Health Organization.

4. Financial need.

5. Academic excellence determined by a copy of the applicant’s transcript and the results of participation in Part I of the National Boards.

6. Extracurricular interests and community service.

7. Letters of recommendation from two faculty members and your Dean submitted directly to the Committee.

8. Statement of the applicant’s method of financial support during the previous years of medical school including a personal income statement of the applicant and spouse, if married.

9. A written statement concerning the applicant’s plan for his or her medical career.
Completed applications will be accepted through April 30 of the year prior to the applicant's graduation from medical school.

THE FOLLOWING QUESTIONS MUST BE ANSWERED BY ALL APPLICANTS

In order to judge your degree of need and your qualifications, the following specific information is required. So far as practicable, it will be regarded as confidential. In view of the facts set forth below, I hereby make application for financial aid for the
year 20 * to 20 Type a label
in accordance with the conditions specified above which I have read.
Academic Information
Legal Name in Full*

First NameLast Name
Email*
example@example.com
Anticipated Year of M.D or D.O Degree*
Local Address for the Upcoming School Year*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Name & Address of High School Attended*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ranking in your Graduation Class*
Premedical Education (College or University)*
Quality Point Average*
Medical School*
School ID #*
Name of Financial Aid Officer at Medical School*
Mailing Address for Bursars Office*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parental Information
Father's or guardian's name in full*

First NameLast Name
Living*
Mother's maiden name in full*

First NameLast Name
Living*
Your Country of Birth*
If Foreign Born, are you a naturalized citizen of the United States?
Your Date of Birth*

MonthDayYear
Date
Please list all dates during which you maintained continuous residence in Connecticut for at least five years*
Financial Information
Total annual gross income of parents or trust funds $blanks* earned by blank* individuals. (Note: No application will be considered unless this information is provided)
How many people are your parents supporting financially? You may explain if you choose to do so.*
Are you married?*

YesNo
Do you contribute to the support of others?*

YesNo
If yes, please explain circumstances.
State below plans towards self-supporting for the coming year.*
Please list any other scholarship awards or assistance you have received during medical school.*
Please list extracurricular interests and/or community service.*
Give details of present indebtedness? This may be included with personal finance statement (see below). You must write the total amount of your indebtedness here.*
Give as personal references the full names and addresses of two present members of your medical school faculty and the Dean. Please be sure all three letters are attached before submitting application.*
Please submit your references below or mail to the following address:

Waterbury Medical Association
P.O. Box 30
Bloomfield, CT 06002
Reference #1

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Reference #2

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Reference #3 (Dean)

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Please state in 150 words or less, your plans for your medical career, including area of specialization, type of practice and location of practice. Please upload a .pdf of your statement.*

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Please include the following with this completed application.
A. Medical school transcript
B. Results of Part I of the Medical Boards
C. Personal financial statement of applicant and spouse, if married
D. Complete statement of medical school expenses – tuition, room, board,books, etc. for the first three years of medical school
Medical School Transcript*

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Results of Part I of the Medical Boards*

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Personal financial statement of applicant and spouse, if married*

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Complete statement of medical school expenses – tuition, room, board, books, etc. for the first three years of medical school*

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CERTIFICATION
(1) I hereby certify that I will use the proceeds of the scholarship only for payment of tuition and required feed, room and board, the purchase of books, instruments and other necessary school supplies and equipment.

(2) I hereby acknowledge that the information submitted here with is true and correct.
Applicant's Signature*

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Date Signed by Applicant*

MonthDayYear
Date
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WELSFORD & MILDRED CLARK MEDICAL MEMORIAL SCHOLARSHIP FUND

Academic Information

Parental Information

Financial Information