2015 Scholarship Application - Summit Endodontic Specialists, Inc.

SUMMIT ENDODONTIC
SPECIALISTS, INC.
2015 Scholarship
Application
RONALD M. WOLF, D.D.S., M.S.
Practice Limited to Endodontics
www.Summit-Endo.com
SCHOLARSHIP CRITERIA & REQUIREMENTS:
- Two $500 scholarships (non-renewable) are available to students intending to enter the dental, medical or any science-related field.
- Applicant must be a 2015 graduating high school senior.
- Must have at least a cumulative 3.0 Grade Point Average (GPA) for junior and senior years in high school.
- Selection will be based on merit, community service, and academic performance.
- Scholarship application must include the following:
- This completed application form with applicant’s signature.
- Copy of official transcript of grades.
- Letter of recommendation from your high school guidance counselor, teacher or health care professional addressing the
reason(s) why you should be considered for this scholarship and also your potential for success in college.
- Letter of acceptance from college.
- Completed application and required attachments must be mailed or delivered in person by Friday, April 3, 2015 to:
Summit Endodontic Specialists, Inc., 3611 Darrow Road, Stow, OH 44224, Attention: Scholarship Committee.
PERSONAL INFORMATION & EDUCATION PLANS:
Name (First, Middle, Last): _________________________________________________________ Date of Birth: _______________
Address: __________________________________________ City: _________________________ State: ________ Zip: _________
Phone: _________________________ E-mail: _____________________________________________________________________
College you plan to attend: ________________________________________________ City: ___________________ State: _______
Check one:
___4-year college/university
___2-year college/university
Have you been accepted?
YES / NO
Anticipated major: ____________________________________________________________________________________________
ACADEMIC INFORMATION:
High School: __________________________________ Anticipated Graduation Date: _____________ Class Rank: _____ of _____
Cumulative GPA: ________ (on a scale of _______)
SAT score: _______ out of _______
ACT score: _______ out of _______
Guidance Counselor: ________________________________________ Guidance Counselor’s Phone: _________________________
GENERAL INFORMATION:
Father’s Name: ________________________________________ Mother’s Name: ________________________________________
Father’s Occupation: ___________________________ Employer: ____________________________ Length of employment: ______
Mother’s Occupation: ___________________________ Employer: ___________________________ Length of employment: ______
Parents’ marital status (check one):
___Married
___Single
___Separated
___Divorced
___Widowed
Ages of siblings and/or step-siblings currently living in household: ______________________________________________________
# of family members living in household: ___ # of college or technical students in your family next year (not including yourself): ___
FINANCIAL INFORMATION:
Projected cost of college, not including housing costs or other fees (first year tuition only): ___________________________________
Other scholarships you have received or expect to receive (if known at this time):
Name of Scholarship: ____________________________________________________________ Amount: _____________
Name of Scholarship: ____________________________________________________________ Amount: _____________
Name of Scholarship: ____________________________________________________________ Amount: _____________
PERSONAL INVOLVEMENT / ACHIEVEMENTS (Attach additional page if necessary):
Extra-curricular activities (list offices held): ________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Sports activities: ______________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Honors/ Awards: _____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Community/ Volunteer/ Church activities: _________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Work Experience (include dates, position, employer, # of hours per week): _______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PERSONAL ESSAY QUESTIONS:
Please attach a separate page, typed, double-spaced (maximum of 2 pages), addressing the following two questions:
1) What are your career objectives, and where do you see yourself in five years?
2) How have you made a positive impact in others’ lives?
I verify that all information given in this application is true, and I understand that falsification of information will result in the
termination of any scholarship granted.
Applicant Signature: _________________________________________________________ Date: ____________________________