Dental Assistant Scholarship Application

Name*

First Last

Address*

Street Address City State ZIP Code

Madison College Student ID Number*

Madison College Email Address*

Phone*

Date of Birth*

High School Name*

Are you first in your immediate family to attend college?*

Yes
No

What is your current student status?

New Student
Continuing Student

You are a new student if you have completed less than 6 credits at Madison College.

How many credits are you enrolled in for the upcoming semester?*

Program*

Are you pursing a career in dental assisting?*

Yes
No

Are you a veteran?*

Yes
No

Ethnic Heritage*

African American
American Indian or Alaskan Native
Asian or Pacific Islander
Caucasian
Hispanic/Latino
Hmong
Tibetan
Other

Other

Introduce yourself (without stating your name) and tell us your story. Also, describe any other major life changes or special circumstances that should be considered in review of your application.*

Tell the scholarship reviewer what you are studying and what type of career you want after graduating from Madison College.*

Tell the scholarship reviewer what you are involved in outside of school. This can include community service, volunteer work, extracurricular activities, work experience, family responsibilities, etc.*

Tell the scholarship reviewer what impact this scholarship would have on your success at Madison College and your long-term educational goals.*

I authorize Madison College to release to Madison College Foundation all relevant information needed to determine my scholarship eligibility which may include but is not limited to information concerning financial resources I may receive, as well as ongoing personal information and college academic records. This information will be used for evaluating the application and awarding the scholarship and will not be published or shared with others. Applications, less Student ID number and address information may be shared with donors or quoted in Foundation materials. To ensure a fair and objective review process, it is the policy of the Foundation not to comment on the deliberation of the scholarship review process. Thus, the Foundation is unable to provide written or oral evaluations to applicants after decisions are made. No provisions exist for reconsideration of awards after scholarships are announced. All applications and supporting materials become the property of the Madison College Foundation and, as such, will not be returned. I certify that the information I have supplied on this application is complete and accurate to the best of my knowledge, and I understand that knowingly submitting inaccurate or false information will result in the denial or loss of any scholarship offers or awards.*

By Signing this application, I agree to all terms and conditions stipulated herein.

Applicant’s Signature (Type your full name)*

Date*