WCMA Scholarship Application The due date for applications is set by The Wichita County Medical Alliance and is May 1, 2020. Name* First Last Age*Date of Birth* MM DD YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Gender*MaleFemaleMarital Status*MarriedSingleDivorcedResident Status*US CitizenLegal ResidentOtherIf Resident Status is "Other", please describe*How many years have you lived in Wichita, Archer, Baylor or Clay County?*PREVIOUS EDUCATION: HIGH SCHOOL AND/OR COLLEGE INFORMATIONHigh School Name*City & State*Graduation Year*SAT/ACT Score*College/University*Number of Credits Earned*GPA*Degree*YesNoAttach your most recent full-time student transcript* Drop files here or College/Univ./medical school you plan to attend in the upcoming fall?*Medical certification/degree being sought*Have you been accepted?*YesNoFinancial InformationEstimate expense for tuition next year*Estimated expense for room/board next year*Estimated expense for books next year*Father's Name*Father's Employer/Occupation*Father's highest level of education*Mother's Name*Mother's Employer/Occupation*Mother's highest level of education*Do you receive living or Education expenses from your parents or relatives?*YesNoIs yes, please explain*Have you applied for Federal/State student financial aid (FAFSA)?*YesNoIf yes, list all funds received in scholarships awarded, grants awarded (federal, Pell, State) and assistance offered by University/college*List your work experience for the last 4 years*EmployerPositionHours per week Click + symbol to add more work experienceReferencesAttach documents from two, non-related adult references who are teachers and one non-related adult reference from someone that has known you more than one year.Reference Attachments* Drop files here or EssayProvide in 100 –200 words, an essay describing, “Why you want to pursue a medical career”. Please include specific information such as your career goals, personal challenges, motivating factors, life goals, work experience, and any other awards or experience that will help us in evaluating your application. Please use the essay to explain your financial need and how this scholarship is useful to you along with other family support you receive. Please take this seriously; be thorough and complete. The essay must be the Applicant’s original work.Essay Attachment* Drop files here or SignatureDate* Date Format: MM slash DD slash YYYY Certification* I agreeI certify that all of the information on this form is accurate and complete to the best of my knowledge. The application package becomes the property of the Wichita County Medical Alliance Scholarship Committee and will not be returned or acknowledged. Falsification of information may result in termination of any scholarship granted. I further certify that the essay included is my original work. I understand that all references are confidential and that no one, including myself, other than the Selection Committee members, may examine them. I certify that my gross income level indicated on this form is accurate and complete to the best of my knowledgeVerification