2011/2012 Dr. Amanda Perez Scholarship: Eligibility
2011/2012 Dr. Amanda Perez Scholarship: Eligibility
2011/2012 Dr. Amanda Perez Scholarship: Eligibility
Page 1 of 5
Application requests, questions, and other inquiries should be sent to the above address or emailed to [email protected] Please title your email: LMSA-WEST DR. AMANDA PEREZ SCHOLARSHIP. Award amounts for scholarships are dependent upon funding raised annually. LMSA-West cannot make any guarantees about the amount to be awarded or the number of awards to be given. Determination of which scholarship to be awarded will be based on the information provided on the application and at the sole discretion of the selection committee.
Page 2 of 5
FAMILY/PERSONAL FINANCIAL STATEMENT: 2011-2012 Academic Year Expenses (estimated) Tuition Books and supplies Room and Board Transportation Other: Total Cost of Education= $ $ $ $ $ $ 2011-2012 Academic Year Income (estimated) 2011-2012 Expected Student Salary Scholarships/Fellowships Federal Pell Grant Student Loans Other Grants $ $ $ $ $
2010 (last year's) Annual Family Income: Father's Gross Annual Income $ Mother's Gross Annual Income $ Applicant's Gross Annual Income $ Spouses Gross Annual Income $ Savings/Investments $ Total number in household Total number of dependents TOTAL 2010 GROSS INCOME= $ Page 3 of 5
Please explain if you do not qualify for financial aid or did not apply, you may also specify any extraordinary, unforeseen, or very unusual expenses. You may include up to 200 words on a separate sheet of paper. This should be separate from your personal statement.
Please include as much information about activities as possible (i.e., hours worked per week, dates of service, descriptions of activities, and your role). Do NOT exceed one page.
Community Service, Volunteer, Leadership, and Clinical Experience(s):
Other:
Page 4 of 5
CERTIFICATION: Student must read and sign below to be eligible for consideration.
I have read and understand the scholarship eligibility criteria. All of the information provided is complete and accurate to the best of my knowledge. By signing below, I am certifying that I am a student with the honest intentions of entering a professional medical career and possess the heartfelt desire towards serving the Latino and other underserved communities with their healthcare needs. I also certify that I will apply this award toward expenses related to my education at a four-year university. I authorize LMSA-West to share or publish my application information when necessary and give permission to share this information for the purpose of recruitment, public relations, or possible fund raising. Application materials will become the property of the LMSA-West Scholarship Committee and will not be returned.
Signature
Date
This scholarship is run by LMSA-West, a non-profit student organization. Please send completed and signed application with all necessary documentation as early in the application period as possible. Incomplete or late application materials will not be considered. RECEIPT DEADLINE IS February 8th, 2012. Email to: [email protected] Mail to: LMSA-West Dr. Amanda Perez Scholarship Attn: Amaranta Craig 1355 Willard Apt B San Francisco, CA 94117 You may submit this application with the following items via mail or e-mail: 1) Personal Statement 2) Letter/Letters of Recommendation 3) Completed Application 4) Transcript(s) from all institutions attended 5) Signed Certification Page 6) Financial Aid Information 7) Enrollment verification letter from 4-year university Application questions, and other inquiries should be sent to the above address or emailed to [email protected] Please title your email: LMSA-WEST DR. AMANDA PEREZ SCHOLARSHIP. THANK YOU FOR APPLYING FOR THE DR. AMANDA PEREZ SCHOLARSHIP, LMSA-WEST WISHES YOU SUCCESS!
Page 5 of 5