Scholarship Application s4

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: