GEORGIA DENTAL HYGIENISTS’ ASSOCIATION
APPLICATION FOR SCHOLARSHIP
Name: _______________________________________________________________
Address: _____________________________________________________________
City: ________________________________ State: ________ Zip: ______________
Phone #: __________________ Email: _____________________________________
Dental Hygiene School: _______________________________ City: _____________
Source and amount of funds available:
Your income: _____________________ Aid from parents: _____________________
Scholarships: _________________________ Loans: __________________________
Name of parent, guardian or spouse: _____________________ Relationship: _______
Address: ______________________________________________________________
City: ________________________________ State: ________ Zip: _______________
Company, Position held: _________________________________________________
Three written character references on separate cover (one to include Dental Hygiene Director or Clinical Supervisor). A separate recommendation form must be used for each reference.
1.
Name: ________________________________________________________________
Address: ______________________________________________________________
City: ________________________________ State: ________ Zip: _______________
2.
Name: ________________________________________________________________
Address: ______________________________________________________________
City: ________________________________ State: ________ Zip: _______________
3.
Name: ________________________________________________________________
Address: ______________________________________________________________
City: ________________________________ State: ________ Zip: _______________
Application deadline September 15th of the current year. Only completed applications will be considered. Completed application should be sent to:
Community Foundation of Southwest Georgia
PO Box 2654
Thomasville, GA, 31799
Questions? E-mail KeashaMyrick