Scholarship Application_Medical Laboratory Technician

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

How many credits are you currently enrolled in?*

Program*

Are you a veteran?*

Yes
No

Are you in your final semester clinical externship?*

Yes
No

Did you complete a FAFSA?*

Yes
No

Ethnic Heritage*

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

Other

15. How have you used your own initiative, experience and/or skills to assist in your future success?*

Describe your current involvement in professional, community and/or extracurricular activities. List the groups and activities, including any leadership positions you have held. For example: Spanish club secretary, peer tutor. If you were unable to participate, provide a brief explanation.*

How do you plan to use your Madison College degree? Explain what your goals are and how you plan to achieve them.*

Additional consideration: Include why you would be a good candidate for a Madison College Foundation Scholarship. Also describe any other major life changes or special circumstances that should be considered in review of your application.*

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 This information will be used for evaluating the application and awarding the scholarship and will not be published or shared with others.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*