DAHL MEMORIAL HEALTHCARE ASSOCIA

DAHL MEMORIAL HEALTHCARE ASSOCIATION

P.O. BOX 46

EKALAKA, MONTANA 59324

(406) 775-8739

HEALTH PROFESSIONS SCHOLARSHIP APPLICATION FORM

NAME __________________________________________________________

First Middle Last

ADDRESS __________________________________________________________

__________________________________________________________

PHONE __________________________________________________________

COLLEGE, UNIVERSITY, AND/OR HEALTH PROFESSIONS PROGRAM YOU ARE ATTENDING OR ACCEPTED FOR ENROLLMENT

∙Name and Address of College of university:

__________________________________________________________

∙Name of Health Professions Education Program:

(nursing, physician assistant, nurse practitioner, physical

therapy, occupational therapy, respiratory therapy,

medical technology, laboratory technology, pharmacy, other)

__________________________________________________________

∙Degree and/or certification and Expected Date of completion:

__________________________ ____________________________

Degree Date

∙Date of Enrollment or Expected Enrollment:

__________________________________________________________

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HIGH SCHOOL ATTENDED

∙Name and Address: __________________________________________

__________________________________________

∙Date of Graduation:__________________________________________

∙Grade Point Average: __________________________________________

∙Academic Honors

and/or Awards: __________________________________________

__________________________________________

∙Other Recognitions

and Achievements: _________________________________________

__________________________________________

∙SAT or ACT Scores: __________________________________________

(specify SAT or ACT)

COLLEGES OR UNIVERSITIES ATTENDED

∙Name and Address:

__________________________________________

∙Curriculum/Major: __________________________________________

∙Degree: __________________________________________

∙Currently Enrolled:__________________________________________

(yes or no)

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∙Date of Graduation: __________________________________________

∙Grade Point Average: __________________________________________

∙Academic Honors

and Awards: __________________________________________

__________________________________________

∙Other Recognitions

or Achievements: __________________________________________

__________________________________________

DEMONSTRATED INTEREST IN THE HEALTH PROFESSIONS

(list and/or discuss any employment, volunteer work, school projects, etc that would give an indication of your interest in and/or understanding of health care delivery systems, health professions education and medical/biomedical research)

___________________________________________________________________

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ESSAY /STATEMENT OF PROFESSIONAL GOALS

(This essay or statement should be no longer than one page. It should describe your reasons for choosing one of the health professions as a career and your interest in and commitment to health care delivery systems. Attach the completed essay to this application form.)

REFERENCES

List three persons as references who can verify your academic and personal qualifications to "qualify for this scholarship award. Please ask your references to submit a letter to the Chairman of the Scholarship Committee:

Scholarship Committee

Dahl Memorial Healthcare Association

P.O. Box 46 "

Ekalaka, Montana 59324

∙Reference: ____________________________

____________________________

∙Reference: ____________________________

____________________________

∙Reference: ____________________________

____________________________

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REQUIRED DOCUMENTS TO ACCOMPANY THIS APPLICATION

∙High School Transcript Verification of SAT or ACT Scores

∙College/University Transcript (if applicable)

∙Verification of Acceptance/Admission to Health Professions

Training Program to a College or University

.Essay/Statement of Professional Goals

DEADLINE FOR APPLICATIONS

The completed application with all attachments must be received no later than MAY 1.

The applications should be sent to:

Chairman of the Scholarship Committee

Dahl Memorial Healthcare Association

P.O. Box 46

Ekalaka, Montana 59324

I agree that if I am awarded a scholarship by the Dahl Memorial Healthcare Association that I will use the money for the intended purpose.

___________________________________ ______________________

Signature of Applicant Date