Liz Courain Madison House Graduate Degree Scholarship Application

Last Name: (Required)

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First Name: (Required)

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Mailing Address: (Required)

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City: (Required)

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State: (Required)

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Zip: (Required)

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Phone Number: (Required)

E-mail Address: (Required)

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Date of Birth: (Required)

I certify that I am a United States citizen or permanent resident of the United States of America. (Required)

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Year of UVA graduation: (Required)

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Degree received: (Required)

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List health care degree program and school you will be attending or are currently enrolled in for the fall of 2013. (Required)

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What are your future goals after graduation from the health care degree program? (Required)

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Participation in the Madison House UVA Med-Services program:

Please tell us about your experience as a Madison House volunteer at UVA Health System: (Required)

In what area(s) did you volunteer, what were your responsibilities, what lessons did you learn that will help you in your chosen health care career, how did this experience make a meaningful impact on your life/education/future?

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What impact do you feel you made on UVA Health System, its patients, families and staff as a volunteer? (Required)

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Awards and Activities: (Required)

List your academic awards, honors and membership activities:

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Financial Assistance: (Required)

List other financial assistance you will receive or have been awarded for this degree (scholarships, grants, financial aid, or other). Submit copy of Student Aid Report (SAR), "summary of FAFSA", if applicable.

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Copy of Student Aid Report (SAR) if applicable.

Extracurricular/Community Activities: (Required)

List your extracurricular activities, hobbies, outside interests and community service:

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References:

Please include information on two individuals who have agreed to write a recommendation for you. Do not use family, friends or Volunteer Services staff. We will send an email to the references you provide below, asking them to complete a brief on-line questionnaire. Please notify your references in advance so they will be expecting our email. The deadline for the references to respond is April 1st. If two references are not received by April 1st your application will be considered incomplete and will not be accepted for review.

Reference #1

Name: (Required)

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Relationship/Role to Applicant: (Required)

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Place of work: (Required)

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Email address: (Required)

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Phone number: (Required)

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Reference #2

Name: (Required)

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Relationship/Role to Applicant: (Required)

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Place of Work: (Required)

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Email Address: (Required)

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Phone Number: (Required)

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I certify that the information provided in this application is true and correct to the best of my knowledge. (Required)

I understand that my application will be reviewed by the Scholarship Committee of the UVA Hospital Auxiliary which will select a winner. I understand that the scholarship funds will be made payable to the school that I will attend.

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