Congo Helping Hands

APPLICATION FOR MEDICAL STUDENT ONE-YEAR TUITION SCHOLARSHIP

Name   _____________________________________  Today’s Date  ________________

Date of Birth_________________________________ Sex (male/female) _____________

Residence (village) ________________________________________________________

Marital Status (single/married/widowed/divorced)  _________________________________

How many members are in your immediate family including yourself and spouse? __________

List the names and ages of your children, if any  __________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 Describe previous education:  _______________________________________________

 ________________________________________________________________________

________________________________________________________________________

Which school of medicine do you wish to attend? _________________________________

Why do you want to study medicine? __________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 _____________________________________________________________________

 Why do you need financial assistance?  Please describe in detail: __________________  

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 List three persons who can validate your need for financial assistance:  ________________

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 What are your intentions after obtaining a medical degree?_________________________

 ________________________________________________________________________

 ________________________________________________________________________

 ______________________________________________________________________

  Please attach a letter of recommendation from an instructor or medical professional.

Who completed this form if other than the applicant? 

 _______________________________________________________________

(printed name, signature and date)

Applicant for nursing financial aid scholarship:  

 _______________________________________________________________

(signature and date)