University of Wisconsin–Madison Division of Continuing Studies

St. Mary's Minority Health Care Scholarship Application

Please attach a copy of your most recent transcript to your completed application and submit to the address below.

Personal information

Name (Last, First, Middle)

Phone (                                    )

Permanent Address (Street, City, State, Zip)

Campus Address (if different from above): (Street, City, State, Zip)

Campus Phone (                                    )

Circle the health care area you plan to major in:

Dietetics Pharmacy
Medical Laboratory Technician Physical Therapy
Medical Technology Radiologic Technology
Nursing Respiratory Therapy
Occupational Therapy  

List the month and year you wish to begin this scholarship program: (                                    )

Circle below the highest academic level completed and list current grade point average (GPA):
(Please submit a copy of your high school or most recent college transcript.)

Current Academic Level:    High School Senior    1st year college    2nd year college    3rd year college

Current Grade Point Average GPA (                                    )

List the name of the school you wish to attend with this scholarship:

Have you applied for college admission? (Circle one)    Yes     No
(If no, you are encouraged to start the admissions process immediately. Scholarship award is contingent on college admission.)

Have you be accepted for college admission? (Circle one)    Yes     No

Honors and awards (high school and college)



Extracurricular Activities (high school or college)
(Offices held, band, sports, clubs, community service, volunteer work, scouts, etc.)



Briefly explain the following: a) reasons why a scholarship should be awarded to you, b) your plans for working in the health care field, and c) your needs for financial assistance. Please use additional pages if necessary.



Employment information

Please list all jobs held whether paid or volunteer work. (Attach an additional sheet if necessary.)

Employer
Address
Phone Number
Job Title
Duties


Dates: mo./yr (                     ) to mo./yr (                     ) 		Employer
Address
Phone Number
Job Title
Duties


Dates: mo./yr (                     ) to mo./yr (                     )

 
Employer
Address
Phone Number
Job Title
Duties


Dates: mo./yr (                     ) to mo./yr (                     ) 		Employer
Address
Phone Number
Job Title
Duties


Dates: mo./yr (                     ) to mo./yr (                     )

Recommendations

Please list three individuals (other than relatives) who could provide a written recommendation for you. At least two of these individuals should be instructors.

Name

Address (Street, City, State, Zip)


Relationship to you:
Name

Address (Street, City, State, Zip)

Relationship to you:
Name

Address (Street, City, State, Zip)

Relationship to you:

I certify that the information included in this application is true and correct to the best of my knowledge.

Applicant Signature and Date

Send to:

St. Mary's Hospital Medical Center
Personnel Department, 707 S. Mills Street
Madison, WI 53715
608-259-5566, 800-236-6101

Recommendation Form   Applicant Flow Data   Scholarship List

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www.dcs.wisc.edu • Updated August 21, 2006