INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR THE
DR. G. KARTHIKEYAN MEMORIAL SCHOLARSHIP
APPLICATION DEADLINE: MARCH 27, 2015
ABOUT THE SCHOLARSHIP
Thank you for your interest in the Dr. G. Karthikeyan Memorial Scholarship. This Scholarship was established
in 2006 by the Karthikeyan family in honor of Dr. G. Karthikeyan, a physician who practiced in Elkins until he passed
away in 1999. Among Dr. Karthikeyan’s most enduring legacies was using his professional skills to benefit underserved communities. During his time in Elkins, he dedicated his life to improving the health and vitality of his patients,
friends and family. This Scholarship seeks to benefit students who exemplify these values and wish to pursue careers in
health care to serve the people of West Virginia. The $750 Scholarship is awarded to one member of the graduating
class of Elkins High School.
ELIGIBILITY REQUIREMENTS
To be eligible for the Scholarship, an applicant must:
1.
Be a graduating senior from Elkins High School during the 2014-15 school year.
2.
Plan to be a full-time freshman student at an accredited college or university in the State of West Virginia for the
2015-16 school year.
3.
Intend to pursue a career in any health care field. (The Scholarship is open to students pursuing careers in any
health care field. Examples include, but are not limited to: counseling, dentistry, medicine, nursing, pharmacology,
physical therapy and public health.)
4.
Intend to begin his/her career in West Virginia.
DIRECTIONS
All application materials should be submitted through the EHS Guidance Office. The applicant and school personnel
are both responsible for ensuring that applications are complete and submitted on time. The completed application must
be received by the Guidance Office on or before the DEADLINE of March 27, 2015.
Part I: Student Information

Please provide complete information.
Part II: School Information

Please provide your weighted Grade Point Average.

Please attach a copy of your official high school transcript, as of the end of the most recent semester.

Please indicate your class rank as of the end of the most recent semester.

Please indicate your SAT and/or ACT score. If you have taken either exam more than once, you only need to
indicate the highest score for that exam. If you have not taken a particular exam, please write “NOT TAKEN.”

Please indicate which college or university you will attend during the 2015-16 school year. If you have not yet
accepted an offer of admission, please indicate all schools from which you currently hold outstanding offers.

Please indicate your intended major. If you have not yet decided on a major, please write “UNDECIDED.”
Part III: Faculty Reference

Please provide the name and contact information of one EHS faculty member who will serve as a reference. We
may consult with the reference during our review of your application.

Please identify your reference’s preferred method of contact (phone, email, etc.).
Part IV: Career Plans

Please indicate which health care field you intend to enter. (See #3 under “Eligibility Requirements” above.)
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
Please indicate the geographic area where you intend to begin your career. Please provide as much detail (for
example, the specific town, county or region) as you are able to give at this time.
Part V: Statement of Interest

Please attach, on a separate page, a brief (250 words or less) statement describing your interest in pursuing a career
in health care. Possible topics for discussion include: (a) how you became interested in a career in health care;
(b) any past experience you have related to health care; and/or (c) a description of your career plans. (NOTE: The
Scholarship administrators historically have assigned the greatest weight to this section of the application.
Please prepare your Statement of Interest with this in mind.)
SUBMISSION OF APPLICATION

By Student: Your completed application should consist of: (1) one-page Application Form; (2) attached Statement
of Interest; and (3) Official Transcript. Please deliver (1) and (2) to the EHS Guidance Office, along with a request
for (3), on or before March 27, 2015.

By Guidance Office: Please deliver (1) Application Form, (2) Statement of Interest, and (3) Official Transcript, to:
Hrishi Karthikeyan
25 Abington Avenue
Ardsley, NY 10502
SELECTION AND PRESENTATION

The Scholarship administrators will select and award the Scholarship to a qualified, eligible applicant who
exemplifies the values of Dr. G. Karthikeyan.

The $750 Scholarship will be presented as part of the EHS Award Ceremony prior to Graduation.
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APPLICATION FORM FOR THE
DR. G. KARTHIKEYAN MEMORIAL SCHOLARSHIP
APPLICATION DEADLINE: MARCH 27, 2015
PLEASE TYPE OR PRINT ALL ANSWERS.
PART I: STUDENT INFORMATION
LAST NAME
FIRST NAME
STREET ADDRESS
CITY
TELEPHONE NUMBER
MIDDLE INITIAL
STATE
ZIP
EMAIL ADDRESS
PART II: SCHOOL INFORMATION
WEIGHTED GPA
(Please attach transcript)
.
CLASS RANK
______ / ______
______ / ________
(your GPA)
(max GPA)
SAT SCORE (if taken)
(your rank)
WHICH COLLEGE WILL YOU ATTEND THIS FALL?
(If undecided, please list all schools from which you hold offers.)
(# of students in class)
ACT SCORE (if taken)
WHAT IS YOUR INTENDED MAJOR (if known)?
PART III: FACULTY REFERENCE
REFERENCE NAME
TELEPHONE NUMBER
PREFERRED CONTACT METHOD (PHONE, EMAIL, ETC.)
EMAIL ADDRESS
PART IV: CAREER PLANS
WHICH FIELD OF HEALTH CARE DO YOU PLAN TO ENTER?
(E.g., Nursing, Medicine, Public Health, Pharmacology, Psychology)
WHERE DO YOU PLAN TO START YOUR CAREER?
(Please identify the geographic area as specifically as possible.)
PART V: STATEMENT OF INTEREST
IN 250 WORDS OR LESS, PLEASE DESCRIBE YOUR INTEREST IN PURSUING A CAREER IN HEALTH CARE.
(IF APPLICABLE, PLEASE MENTION ANY RELEVANT PAST EXPERIENCE – CLASSES, ACTIVITIES, VOLUNTEER WORK, ETC.)
PLEASE ATTACH YOUR STATEMENT ON A SEPARATE PAGE. (NOTE: The Scholarship administrators historically have assigned
the greatest weight to this section of the application.)
CERTIFICATION
I certify that the above information is accurate, and I understand that failure to provide the requested information by
March 27, 2015 will disqualify me from consideration for the Scholarship.
_________________________________________________________
SIGNATURE OF APPLICANT
________________________
DATE