Purpose

GeneralScholarshipApplication

InformationandInstructions

ThemissionoftheWisconsinMedicalSocietyFoundationistoadvancethehealth ofthepeopleofWisconsinbysup- porting medicalandhealth education.TheFoundation’sScholarshipProgramofferssupporttooutstandingmedicalstu- dents. Preference is giventostudents from Wisconsinwhodemonstratetiestotheircommunityandadesiretopracticein Wisconsinuponcompletingtheirtraining.

ApplicationDeadline

ApplicationsmustbereceivedbyFebruary1priortotheacademicyearinwhichthestudentwishestoattend.

Selection

Scholarshipsarerecommendedbyareviewcommitteethatevaluatesapplicantsonthefollowingcriteria:

• Financialneed• Personalqualitiesandstrengths

•Academicachievement• Lettersofrecommendation

Thisapplicationisusedtoapplyforthescholarshipslistedbelow.Visitandsearch scholarshipsfordetails.

• EdmundJ.andEstelleD.WalkerScholarship

• Goodman-GoodellScholarships

• RobertJasonGoreScholarship

• JohnD.andVirginiaRieschScholarship

• CatherineSlota-Varma,MD,Scholarship

• RukminiandJoyceVasudevanScholarship

• Victor A. Baylon, MD, Memorial Scholarship

***IMPORTANTINSTRUCTIONS***

Itistheapplicant’sresponsibilitytoseethatallsupportingdocumentsaresubmittedtobereceivedbythe

WisconsinMedicalSocietyFoundationbyFebruary1.

1. Applicationform / Sendto: / Program Coordinator
2. Personalstatement / WisconsinMedicalSocietyFoundation,Inc.
3. Transcripts / 330ELakesideSt,Madison,WI53715
4. Lettersofrecommendation / Phone:608.442.3800or866.442.3800
5. FinancialAwardLetter(ifavailable) / Fax:608.442.3851
Email:

AllcandidateswillbenotifiedoftheirapplicationstatusbyApril.

APPLICATION

Section 1:

Eligibility: This eligibility screening helps to determine which scholarships you will be considered for receiving. You must be a US Citizen attending a qualified institution for the next school year. You do not need to meet all the qualifications listed below to be considered for a scholarship from the Wisconsin Medical Society Foundation.

  • Are youaUnitedStatescitizen? Y/N
  • Are youa full-timestudentenrolledinmedicalschoolatanaccreditedinstitutioninWisconsin? Y/N
  • Are youconsidered a Wisconsinresidentsfortuitionpurposes? Y/N

Additional Eligibility Screening: This eligibility screening helps to determine which scholarships you will be considered for receiving. You do not need to meet all the qualifications listed below to be considered for a scholarship from the Wisconsin Medical Society Foundation.

  • Have you completed at least one year, or are you in the process of completing one year of medial school?
  • Are you enrolled in the School of Nursing at UW-Madison? Y/N
  • Are you from Racine or Milwaukee County and pursing a degree in medical technology or science?
  • Are you from Racine or Milwaukee County and pursing a medical degree? Y/N
  • Have you held leadership roles in the AMA, WMS or your County Medical Society?Y/N
  • Do you have ties to the Sheboygan area? Y/N
  • Are you a veteran? Y/N
  • Have you had life experiences that exemplify chivalry, honor and loyalty? Y/N
  • Are you an M2 with ties to the Portage area and do you have an interest in pulmonology or general family practice? Y/N
  • Are you a female student who will be an M3 or M4 who has overcome unusual or significant adversity or obstacles in life? Y/N
  • Do you wish to practice in Wisconsin when you complete your training? Y/N

Section 2:

Basic Information:

First Name:

Middle Name:

Last Name:

School: Check: MCW, UW School of Medicine & Public Health, Other: Please List:

School ID:

In the Fall, what year in school will you be: Check: First, Second, Third, Fourth, Other: List

Major/Specialty You are Considering:

Number of Credits in the Fall:

Anticipated Graduation Year: Ex: 2017

Marital Status: Single, Separated, Divorced, Married, Widowed

Number of dependents under the age of 18:

What is your current Street address:

What is your current City

What is your current State

What is your current Zip

What is your current Phone

School Email

What is your permanent Street address

What is your permanent City

What is your permanent State

What is your permanent Zip

What is your permanent Phone:

Non-School Email

What is your School Financial Aid Street Address:

What is your School Financial Aid City

What is your School Financial Aid State

What is your School Financial Aid Zip

What is your School Financial Aid Phone

Date of Birth:

City of Birth:

County of Birth:

Name of High School Attended:

City:

County:

State:

Zip:

PersonalStatement – Limit 700 word or 5000 characters with spaces.

Thisstatementisanimportantaspect ofthisapplicationandistheequivalentof aninterview.

Please addressthefollowing:

a)family background

b)achievements

c)currenthighereducationstatus

d)careergoals includingpracticetype(s)ofmost interest(specialty,primarycare,urban,rural,academic,etc.)

e)financialneedforthisscholarship

f) examples of your leadership

g) examples of your volunteerism;

h) unusual circumstances

i) anyotherinformationrelevanttothisapplication.

Section 3:

Financial Information:

Do you expect to be employed this year: Yes/No

If Yes:

Type of work:

Hours per week:

Total School debt including undergraduate and student loans:

Anticipated Student Loan amount for next year:

Estimated Income:

What are your estimated household earnings for next year:

What are your estimated parental contribution for next year:

What are your estimated earnings for next year:

What are your savings:

What are your estimated assistance form government agencies next year:

What are your estimated scholarships for next year:

What are your estimated fellowships for next year:

What are your estimated grants for next year:

What other income do you anticipate for next year:

Explain

Total income for Next Year:

Estimated Expenses:

What are your estimated tuition expenses for next year:

What are your estimated books and supplies expenses for next year:

What are your estimated housing expenses for next year:

What are your estimated transportation expenses for next year:

What are your estimated household expenses for next year (include insurance, living expenses, food, medical, dental, etc.): What are your estimated other expenses for next year:

Explain

Total expenses for next year:

Subtract total income from total expenses for total unmet need:

Are you considered Self Supporting for Financial Aid purposed based on federal financial aid (FAFSA) criteria?

Yes/No

If Yes, please go on to section 4. If No, please answer the following:

Father’s Name:

Occupation:

Annual Income:

Address:

City

State:

Zip:

Phone:

Mother’s Name:

Occupation:

Annual Income:

Address:

City

State:

Zip:

Phone:

Number of siblings claimed as dependents by parents:

How many are in college, including you?

Parent’s current marital status:

Section 4:

Additional Information:

Nameofcollegeororganizationfromwhichyoureceivedthisapplication:

Newspaper(s)tocontactifawardedascholarship.

Name:

City:

Name:

City:

Name:

City:

Itistheapplicant’sresponsibilitytoseethatallofthefollowingdocumentsaresubmittedtobereceivedbythe

WisconsinMedicalSocietyFoundationbyFebruary 1.

  1. Transcript:Atranscript (may be unofficial) or verification of most recent course status mustaccompanythisapplication.
  1. References – Limit of one page each. Twoletters ofrecommendationarerequired,preferablyfromschool officials whocandiscussyourachievements which may include leadership and volunteer activitiesaswellasyourpotentialforfuturesuccess.Apreferredformat fortherecommendationletters can be found here. (link to: Theletters maybesentwithyourapplicationordirectlytothe WisconsinMedicalSocietyFoundationtobereceivedbyFebruary 1.

Please send to:

Program Coordinator

Wisconsin Medical Society Foundation, Inc.

PO Box 1109

Madison, WI 53701

Phone: (608) 442-3889 or (866) 442-3800

Fax: (608) 442-3851

Email:

CERTIFICATION:

By checking this box I certify alloftheinformationprovidediscompleteandaccuratetothebestofmyknowledge.IherebygivetheWisconsin MedicalSocietyFoundationScholarshipSelectionCommitteepermissiontosharethisinformation,withtheexception ofmyfinancialinformation,forthepurposeofrecruitment,andpublic relations.Ifurther certifythatIamcurrently enrolledinamedicalschool orinanursingorrelatedhealth career programatanaccreditedcollegeoruniversityfor theupcomingacademicyear,andwillusetheFoundationScholarshipAwardtoward expensesrelatedtomyeducation. Falsificationofinformationmayresultinterminationofanyscholarshipgranted.Allapplicationmaterialsbecomethe propertyoftheWisconsinMedicalSocietyFoundation.