Scholarship Application – First Year

Complete the application below by April 1 for consideration for a $1,000 scholarship from the Madison County Health Trust, Inc.

Personal Information
Name*
First Last
- Email*
- Daytime Phone*
- Home Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Education
- High School Attended*
- Graduation Year*
- Official Transcript – Current GPA / Class Rank*
  Max. file size: 2 MB.
- Additional Certifications Attained
- University or College You Are Currently Attending or Plan to Attend*
- Major/Program*
- Degree/Certification to be Pursued*
- Expected Month/Year of Graduation*
- School Enrollment Confirmation*
  Drop files here or
  
  Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 2 MB.
  Provide validated registration or enrollment in an accredited program (acceptance letter from school’s program or a list of your upcoming classes from school portal)

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Essay
Share your passion and desire for a career in your chosen healthcare field. Include any employment, volunteer and leadership experience.
Personal Essay*

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References
Please provide two (2) signed letters of reference. References may be from high school teachers, college professors and current or previous employers – NOT personal friends or relatives.
Letters of Reference*
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 2 MB.

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Sign & Submit
I have read and agree to the guidelines of this application. I certify all information provided in my application is accurate and hereby request to be considered for the scholarship.
Applicant Signature*
Date*
MM slash DD slash YYYY

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Personal Information