Rev. March 2017
AUSTIN-BAILEY HEALTH AND WELLNESS FOUNDATION
SCHOLARSHIP APPLICATION FORM
PERSONAL INFORMATION:
Name:
Home Address:
ACADEMIC INFORMATION:
School:
Current Class Year: Sophomore Junior Senior Graduate Student
Course of Study or Major:
Expected year of graduation: Cumulative GPA:
Expected enrollment status for next semester: Full-time _______ Part-time hrs.
EXTRA-CURRICULAR ACTIVITIES: Please list activities in which you have participated and any awards or honors received.
YOUR ASPIRATIONS: Please tell us why you have chosen to major in a health-related program. Demonstrate or describe
financial need or exceptional circumstances and explain how receiving this scholarship will assist you in achieving your goals.
RELEASE OF INFORMATION: I authorize the financial Aid Office to exchange financial, academic and other information deemed
necessary in determining my eligibility for this scholarship. I agree to allow the Scholarship Committee to verify any and all information
with the appropriate campus offices. I also agree to the release of my information for public relations and/or news releases in conjunction
with this scholarship. In signing this application, I certify that the information given is complete and correct.
Applicant’s Signature Date
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signature
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