Please complete form, save to your computer and print to submit with other materials. Additional pages may be attached if needed. Please include your name, address and name of the scholarship on all attachments.
APPLICANT INFORMATION
Name of scholarship(s) applying for
Last Name First Middle
Home Address
City State Zip Phone
E-Mail Date of Birth
PARENT(S)/GUARDIAN (If not applicable, please include applicant information)
Last Name First Middle
Last Name First Middle
Complete if Fremont Area Medical Center employee:
Job Title Department Full-time Part-time
Phone Relationship to Applicant Applicant is a dependent Yes No
HIGH SCHOOL
School Name Graduation Date: Month Year
City State Telephone
ACT or SAT Class Rank # in Class GPA
POST-SECONDARY SCHOOL(S) (If applicable)
List post-secondary school(s) attended. Please use official school names, not abbreviations.
Name CityState
Name City State
4 yr College/University Community/Junior College Vocational Technical School Other
Year in post-secondary program next school year 1 2 3 4 5 Graduate Study
Major or course of studyAnticipated date of graduation
Anticipated degree: BA/BS Associate Certificate
Student will live on campus live off campus commute from home
If school choice is a public institution, applicant will pay: in-state resident tuition out-of-state tuition
TRANSCRIPT INFORMATION
- Students currently or previously enrolled in college or technical school must include transcripts of all grades.
- High school seniors and applicants who have competed less than one full quarter or semester of post-secondary education must include a high school transcript of grades.
GOALS AND ASPIRATIONS
Describe how your educational and career plans relate to your long-term goals.
SPECIAL CIRCUMSTANCES
Describe circumstances that may affect you or your family in regard to financing your post-secondary education.
SCHOLARSHIPS AND AWARDS
Please list the name and amount of any grants or scholarships you have been awarded for the coming school year.
Award Name, School and Amount
Granted Pending
Granted Pending
Are you eligible for a Pell Grant? Yes
APPLICATION CHECKLIST
Please submit a completed application and attach the following materials:
Cover Letter
Resume (include extra curricular activities, commnity involvement, leadership and employment)
ranscript(s) for high school and/or all post-secondary institutions attended.
Submit completed application and attachments to:
Fremont Area Medical Center Foundation
Attn: Scholarship Committee
450 East 23rd Street
Fremont, NE 68025
I meet the basic eligibility requirements of the scholarship(s) for which I am applying and the information provided is complete and accurate to the best of my knowledge. I understand that falsifying information may result in my disqualification for any Fremont Area Medical Center Foundation scholarship.
Applicant’s Signature ______Date
Fremont Area Medical Center Foundation’s Scholarship Committee has the sole responsibility for selecting recipients based on criteria outlined in the scholarship description. The Foundation Board of Directors must approve the scholarship awards and all decisions are final.
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