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SCHOLARSHIP APPLICATION
INSTRUCTION SHEET
Eligibility:
Must be a resident of Jefferson County
High School graduate or graduating in June of this year
Pursuing a degree in a HEALTH RELATED FIELD (no pre-med considered this year)
Immediate family members, of a physician eligible for membership in the
Jefferson County Medical Society, are NOT eligible for this scholarship
Requirements:
1. COMPLETED* attached application
2. Official high school or college transcript from most recent year of
study, including most recent grade report (FIRST YEAR COLLEGE
STUDENTS, PLEASE INCLUDE HIGH SCHOOL TRANSCRIPTS)
3. Two CURRENT letters of reference from people outside your family
4. Essay of ONE page (350 words MAXIMUM) explaining:
a. Your reason for entering your chosen health field of study
b. Why you are the best candidate for this scholarship
c. Your special circumstances that create financial need
Awards Based on:
Academic excellence (85% grade average or better)
Financial need
Personal essay (spelling, grammar and following directions)
Applicants references
Payment of scholarship will be sent directly to your educational institution in August,
2016
Deadline: COMPLETED* application package postmarked no later than May 1, 2016
application (3 pages)
essay
transcripts
two letters of reference
Mail to:
Mrs. Patricia Minaert
19034 Star School House Road
Dexter, NY 13634
*Incomplete application packages will NOT be considered. You may call 78-8766 with any questions.
Revised 1/10
Applicant
Data
____
First
MI
_________
Street
____________________________
Apt #
______
City
State
_________
Zip
______________________
County
Tel. # (____)___________________
Date of Birth: ______________________Social Security Number: _________________
College major or intended field of study: _________________________________________
Parent/
Guardian/
Spouse
____
First
MI
Address: ____________________________________
________
Street
Apt #
(if applicable)
____________________________
______
City
State
_________
Zip
_____________________
County
_____________________________________
Name
_____________________________________
Name
_______________
Relationship
_______________
Relationship
_______________
Relationship
________
Age
_________
Grade
________
Age
________
Age
_________
Grade
_________
Grade
_____________________________________
Name
________________
________
Relationship
_________
Age
Grade
Page 2
School
Data
applied
have been accepted
currently attending
PLEASE CHECK APPROPRIATE BOX
College Name:
____________________________________________________
College Address: _____________________________________
Street
________________________________
City
________
State
____________
Zip
List any Post secondary schools you have attended. Include dates and degrees obtained.
Transcript
Information
Degree: _____________
Degree: _____________
Verbal ___________
Math ___________
Math ___________
Cumulative Grade Point Average _______ Current Semester Grade Point Average ______
A copy of your transcript and recent grades MUST be submitted along with this application.
st
If you are a 1 year college student, please submit your high school transcript, in addition.
Anticipated
Expenses
Tuition/year $__________________
Room/Board $______________________
Books: $______________________
Fees: $_______________________
Amount $______________
Name ____________________________________
Amount $______________
Name ____________________________________
Amount $______________
Name ____________________________________
Amount $______________
Page 3
Work
Experience
Describe your work experience during the past four years. List dates of
employment in each job and approximate number of hours worked each week.
List amount earned at each job.
Activities
Award
and
Honors
Company/Position
Dates of Employment
Hours/week
Amount Earned
________________
__________________
___________
___________
________________
__________________
___________
___________
________________
__________________
___________
___________
________________
__________________
___________
___________
List school activities in which you have participated during the past four years (i.e.:
music, sports, student government etc.) List community activities you have participated
in without pay during the last four years (i.e.: scouts, hospital, volunteer, etc.)
School Activities
Activity
#Years
Awards/Honors
Offices Held
_________________________
_________________________
_________________________
_________________________
Community Activities
_________________________
_________________________
_________________________
_________________________
It is your responsibility to notify the Scholarship Chair immediately if any of the information on this
application changes (i.e.: if you change major/field of study or are not accepted/do not attend the school
indicated).
I hereby certify all of the above information to be correct and accurate to the best of my knowledge.
______________________________________
Signature of Applicant
__________________________________
Date of Signature
___________________________________
Printed Name of Applicant