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ALLIANCE with the MEDICAL SOCIETY of JEFFERSON COUNTY

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

ALLIANCE WITH THE MEDICAL SOCIETY OF JEFFERSON COUNTY


SCHOLARSHIP APPLICATION
Name: ________________________ _____________________________
Last

Applicant
Data

____

First

MI

Permanent Address: ____________________________________

_________

Street

____________________________

Apt #

______

City

State

_________
Zip

______________________
County

Tel. # (____)___________________
Date of Birth: ______________________Social Security Number: _________________
College major or intended field of study: _________________________________________

Name: ________________________ _____________________________


Last

Parent/
Guardian/
Spouse

____

First

MI

Address: ____________________________________

________

Street

Apt #

(if applicable)

____________________________

______

City

State

_________
Zip

_____________________
County

Relationship to Applicant: _______________


Is the applicant a dependent __Yes ___ No
Applicants Yearly Gross Income: ____________________
Applicants Employer: _________________________ Occupation: ___________________
Length of Employment: ________________________
Financial
Data
Fathers Income ___________Employer: __________________ Occupation: __________
Mothers Income ___________Employer: __________________ Occupation: __________
Spouses Income ___________Employer: __________________ Occupation: __________

Names/Ages/Grades of all dependents in household:


_____________________________________
Name

_____________________________________
Name

_____________________________________
Name

_______________
Relationship

_______________
Relationship

_______________
Relationship

________
Age

_________
Grade

________
Age

________
Age

_________
Grade

_________
Grade

_____________________________________
Name

________________

________

Relationship

_________

Age

Grade

Page 2

Applicants Name: ___________________________________________

School
Data

High School Name: _______________________________ Date of Graduation: _________


Accredited colleges to which you have

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

School Name: _______________________________ Date: ___________

Degree: _____________

School Name: _______________________________ Date: ___________

Degree: _____________

SAT Scores: Verbal ___________


ACT Scores:

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: $______________________

Travel to/from School: $ ______________

Fees: $_______________________

Child Care: $ ________________________

Others (list type of expense) ___________________________________________


____________________________________________________________________
_____________________________________________________________________

TOTAL Anticipated Expenses $ ______________________ per year


Applicants Savings $________________________
Anticipated
Resources

Parent/Guardian/Spouses expected annual contribution: $________________


Other Scholarships received or anticipated:
Name ____________________________________

Amount $______________

Name ____________________________________

Amount $______________

Name ____________________________________

Amount $______________

Name ____________________________________

Amount $______________

Page 3

Applicants Name: _______________________________________________

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

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