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Name:___________________________________________________________________

Address: ________________________________________________________________

Phone number:___________________________

Email address:____________________________

Can we contact you via facebook? _______________ If yes, please explain how: _________________________

1. Please discuss what health related field you aspire to go into: _______________________________________________

__________________________________________________________________________________________________________________

2. Do you know anyone personally who is in this field?____________ If yes, please explain:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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3. Have you shadowed anyone in this field? __________ If yes, please explain: ____________________________________

__________________________________________________________________________________________________________________

4. What if hypothetically this field never existed, what would be your second field of choice and why? ____________________________________________________________________________________________________

____________________________________________________________________________________________________

5. What will it take for you to obtain your goals? _________________________________________________

____________________________________________________________________________________________________

6. What is the biggest roadblock you will need to overcome to achieve your goals?___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ 

7. What school(s) do you plan to attend and why? ________________________________________________________

_____________________________________________________________________________________________________________

8. What is your grade point average? _____________________

9. What is your ACT scores? ______________________________

10. Have you received any awards? _____________ If yes, please describe:______________________________________________

______________________________________________________________________________________________________________________

11. Would you be willing to have a phone interview by some of the Board members of HPGF? ___________

12. Do you have any siblings in college? _________________

13. If yes to the above question, what college are they going to and what are they studying? __________________________

_______________________________________________________________________________________________________________________

14. Please list any community service you participated in during the last 4 years and explain in details what your role was.

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

15. Were you in any leadership roles in the last 4 years? _____ Please explain: _________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

16. What jobs have you worked on and how long? _____________________________________________________________________

_________________________________________________________________________________________________________________________

17. What were your responsibilities in those jobs, and what did you learn from the experience of working?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

18. Do you plan on working while you go to College? ___________ Why? ____________________________________

19. Please explain why you think HPGF should grant you a scholarship?____________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

20. Please describe what you do in your free time. ______________________________________________________

_________________________________________________________________________________________________________

21. Do you have any hobbies or sports you are / have been involved in? __________________________________

_________________________________________________________________________________________________________

I certify the information provided is complete and accurate to the best of my knowledge and understand that falsification of information may result in award termination.

Signature___________________________________________ Full Name: ____________________________________ Date:______

Please attach any pictures and letters of reference from educators, employers, pastors, Boy or Girl Scout leaders and any information you would like us to consider.

Please send this application with attachments to: HealthProfessionalGF@gmail.com.