WISCONSIN ACADEMY OF NUTRITION AND DIETETICS

Scholarship Application Form

Please note: Each year the WAND Board of Directors votes on whether or not scholarships are available based on the recommended budget provided by the WAND Finance Committee. The Jo Saunders Student Scholarship is the only scholarship that is available this year.

Check appropriate scholarship for which you are applying: (may receive a scholarship only once in each category)

Jo Saunders Student Scholarship - $500.00

Completed applications must include the following items:

  1. Official transcript from all universities/institutions attended where 5 or more hours have been earned.
  2. Completed application form.
  3. Three (3) letters of reference.
  4. Resume.
  5. Include additional sheets to answer questions as needed.
  6. Send all information in one packet.

Please Print or Type

Name______Contact phone number: (______)______

Last/First Maiden Name

Permanent Legal Address______

Street/Post Office Box ______

City State Zip

Present Address______

Street/Post Office Box

______

City State Zip

Email address: ______

List of Universities or schools attended after high school graduation:

University______Year:______

University______Year:______

University______Year:______

University______Year:______

List Names and Addresses of three (3) references from whom letters of recommendations were received:

1.______

______

2.______

______

3.______

______

List Professional Organizations and/or Extracurricular Activities: Extra points will be given if a member or have applied for membership to Academy and WAND.

Names of OrganizationOffice Held or Contribution

______

______

______

FINANCIAL STATEMENT

EXPENSESMONTHLY GROSS INCOME

Tuition per Semester ______Wages Monthly ______

Books/Fees per Semester ______Family Contribution______

Rental Expense ______School Loans/Grants______

Home Mortgage per Month ______Scholarship______

School Loan Payments______Savings Account ______

Transportation Costs ______Interest on Savings Account ______

Child Care Costs ______AFDC Payments______

Estimated Medical Expenses per Month ______Social Security Benefits ______

Other______V.A. Benefits ______

Other ______

Volunteer/Work Experience – Attach Resume

Place of EmploymentYearHrs/WeekDescription of Duties

______

______

______

______

Briefly summarize your professional and career goals and what you hope to contribute to the profession of dietetics.

______

______

______

______

______

Expected Graduation Date: ______Current Status: ___Sophomore ____Junior ____Senior ___Diet tech (student)

Cumulative Grade Point Average (include transcript): ______

The data I have submitted is correct to the best of my knowledge. I certify I am a Wisconsin resident or qualify for in-state tuition and have completed or are taking the required number of credits for the scholarship I am applying for. I also intend to complete an Academy approved internship, coordinated undergraduate program, graduate program or dietetic technician program. I will promptly report any changes in the information I have provided which will aid the committee in determining my need or merit.

______

SignatureDate

Mail to: WAND Scholarship Committee DUE BY: February 15 - either postmarked by

563 Carter Court, Suite Bthis date or emailed by 5:00 pm CST -

Kimberly, WI 54136 WAND Office
Contact phone number1-888-232-8631

or

Revised November 30, 2015