SCHOLARSHIP APPLICATION
Applicant’s Name ______E-Mail Address ______
Permanent Address ______
Street Address
______
City State Zip County
Phone ______Date of Birth______
Home Cell
High School ______Graduation Date ______
(specific)
City ______State ______
Cumulative Weighted GPA ______(written proof required)
Are you the first person in your family to attend college? YES NO
What are your plans for the future? ______
______
______
List your community and extracurricular activities: ______
______
______
______
Required Attachments:
Essay: How has your experience with Dothan Pediatric Healthcare Network (clinic specific for Dothan, Eufaula, Enterprise, or Ozark) affected you as you have grown? (500 word maximum)
Copy of High School Transcript
2 Scholarship Reference Forms (1-Personal, 1-Academic/Professional)
I hereby authorize Dothan Pediatric Healthcare Network access to information from my medical records for scholarship application purposes. I give approval and understand my photo may be taken and posted on social media for recognition. I certify the information in the application is true, complete, and correct to the best of my knowledge.
Applicant Signature: Date: