CAMERON REGIONAL MEDICAL CENTER, INC. 2014 RENEWABLE SCHOLARSHIP APPLICATION
Only typed applications will be considered. Please answer all questions completely. This application must be postmarked to CRMC no later than Friday, April4, 2014,or HAND-DELIVERED TO CRMC NO LATER THAN 3:00 P.M. onFriday, April4, 2014.Late applications will not be considered.Minimum ACT score of20 required.If placed on the Internet for completion, form must not be altered, distorted or lengthened. (Please see Page 3.)
NAME ______TELEPHONE ______
FirstMiddleLast
ADDRESS ______
StreetCityStateZip Code
COUNTY OF RESIDENCE ______HIGH SCHOOL ______DATE OF BIRTH ______
FATHER’S NAME ______OCCUPATION ______
MOTHER’S NAME ______OCCUPATION ______
LIST SIBLINGS, AGES, & WHETHER THEY ARE IN COLLEGE ______
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In the space below, briefly summarize your school, church, and community activities. List organizations in which you are active and any offices held. ______
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Please list any special honors received, including those from academics, extra-curricular activities, and athletics. ______
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SCHOOL YOU PLAN TO ATTEND ______
Name
______
AddressCityStateZip Code
CAREER PLANS ______
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DATE YOU PLAN TO ENTER COLLEGE ______
TYPE OF HOUSING: _____COMMUTE ______LIVE WITH RELATIVES/FRIENDS ______DORMITORY
______FRATERNITY/SORORITY______LIVE OFF CAMPUS
RETURN TO: Carol Arthur, Administration Page 2 of 3
Cameron Regional Medical Center, Inc.
P. O. Box 557; 1600 East Evergreen
Cameron, MO 64429
PLEASE LIST BELOW THE EXPENSES YOU ANTICIPATE AND THE RESOURCES YOU HAVE FOR MEETING THESE EXPENSES. COSTS SHOULD BE FOR THE SCHOOL YEAR, AUGUST THRU MAY.
Tuition, Fees ______Personal Savings ______
Room, Board ______Summer Employment ______
Other Fees ______Contribution from Parents ______
(Lab, music, etc.)
Books/Supplies ______Loans ______
Personal ______Benefits ______
(Clothing, recreation, medical, etc.)(Veterans, Social Security, etc.)
Transportation ______Scholarships ______
(Round trips/Commute miles) ______
Other expenses ______Other resources ______
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TOTAL $______TOTAL $______
What advanced math and science classes have you taken in high school? ______
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Why are you choosing the medical field as a career? ______
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Indicate what you have done in planning ahead to help meet your anticipated college expenses. How have you earned or saved money, and what will be your plans for the coming summer?______
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The applicant, by signature below, certifies the information herein contained to be both true and accurate to the best of his/her knowledge. The applicant also herewith consents that the Scholarship Committee of CRMC may be fully informed as to the applicant’s scholastic standing, character, and other factors having a bearing on this application.
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SOCIAL SECURITY NO.APPLICANT’S SIGNATURE
RETURN TO: Carol Arthur, Administration Page 3 of 3
Cameron Regional Medical Center, Inc.
P. O. Box 557; 1600 East Evergreen
Cameron, MO 64429
ACADEMIC INFORMATION
(to be supplied by Counselor/Principal)
Class Rank ______/______SeniorsGPA ______on a 4.0 Scale
ACT Test Results:
Raw Score:ENG ______MATH______READING______SCIENCE______COMP______
Percentile: ______
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Date CompletedSignature of Counselor/Principal
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Telephone No.
PLEASE READ ALL INSTRUCTIONS CAREFULLY. STUDENT MUST RESIDE IN CALDWELL, CLINTON, DAVIESS, DEKALB, OR HARRISON COUNTY IN ORDER TO BE ELIGIBLE. THIS APPLICATION MUST BE POSTMARKED TO CRMC NO LATER THAN FRIDAY, APRIL 4, 2014, OR HAND-DELIVERED TO CRMC NO LATER THAN 3:00 P.M. ON FRIDAY, APRIL 4, 2014.
This application is available at However, NO ELECTRONIC SUBMISSION OF THE COMPLETED APPLICATION WILL BE ACCEPTED. The completed application must be mailed via USPS or delivered in person.