Scholarship Application

Please prepare your application carefully.

Please feel free to attach additional sheets of paper as necessary. We are seeking to know about your unique situation and why we should award a scholarship to you rather than the other applicants. The answers to these questions will be kept in confidence.

Biographical Data

Michigan PA Program   CMU   GVSU   UDM   WMU   WSU

Name _____________________________________________________________________

Address ___________________________________________________________________

Evening Telephone ___________________________________________________________

Cell phone or pager____________________________________________________________

Marital status _________________________________________________________________

Dependents and ages___________________________________________________________

On what day will/did you enter your final year/half in your PA

Program?____________________________________________________________________

Financial Resources____________________________________________________________

_____________________________________________________________________________

Current employer, if any_________________________________________________________

Position ______________________________________________________________________

Expected annual income from employment___________________________________________

Amount of grants/scholarships for first year of program________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Amount of grants/scholarships for second year of program______________________________

_____________________________________________________________________________

_____________________________________________________________________________

What do you estimate your level of student debt will be upon graduation?__________________

____________________________________________________________________________

Financial support from other sources_______________________________________________

_____________________________________________________________________________

Total annual income for 2003 $

Professional Memberships________________________________________________________

Current AAPA member/fellow?   Yes    No

Current MAPA member/fellow?   Yes   No

  Please attach a brief narrative discussing the following points:

* Tell us why your academic record is outstanding.

* List any honors, awards, or special recognition that you have received.

* Describe a significant learning experience that occurred during your PA education that influenced your professional development.

* Discuss your involvement in activities sponsored by student professional academies/organizations.

* Please give examples of how you have helped to support other PA students or helped to interest others in the PA profession.

* What are your past, present, and future plans to serve your community through volunteer work

* Discuss your financial needs.

Scholarship Criteria

Financial need...................................................... 40%
Scholarship.......................................................... 20%
Professional involvement........................................ 20%
Community service.................................................20%

Please return by July 1 2004 to:

US Mail
David Martin, PA-C
Chairperson Scholarship Selection Committee
Michigan Physician Assistant Foundation
1349 Avondale
Sylvan Lake, MI 48320
248 898 7113

Please have your Program Director complete and return the following information:

Program Director Verification of Student Status

Student¹s Name _____________________________________________________________

Date of graduation _____________

Student current grade point average _________________

The person named above is currently enrolled and is in good standing in our Physician Assistant Program. The grade point average and graduation date given above is correct.

Program Director Typed Name or Signature ___________________________________
Institution_______________________________________________________________
Today¹s Date____________________________________________________________

Please return by July 1 2005 to:

David Martin, PA-C
Chairperson Scholarship Selection Committee
Michigan Physician Assistant Foundation
1349 Avondale
Sylvan Lake, MI 48320