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Scr C

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South Baylo University
Anaheim Main Campus: 1126 N. Brookhurst St., Anaheim, CA 92801-1701
Tel: 714-533-1495 Fax: 714-533-6040
Los Angeles Campus: 2727 W. 6th St., Los Angeles, CA 90057-3139
Tel: 213-738-0712 Fax: 213-480-1332
SBU_admin-86
SBU SCHOLARSHIP REQUEST FORM - CLINIC
STUDENT NAME:
STUDENT ID # : EMAIL:
ADDRESS:
PHONE NUMBER: FULL-TIME STUDENT (Y/N)
SBU WORK STUDY STUDENT (Y/N) FEDERAL WORK STUDY STUDENT (Y/N)
FIRST QUARTER OF INTERNSHIP (DATE):
REASON FOR FINANCIAL ASSISTANCE:
Student Signature Date
PLEASE READ THE BACK.
Last First Middle
SCR-C
Revised 2/10/2020
SBU_admin-87
SBU SCHOLARSHIP REQUEST FORM - CLINIC
QUESTIONS AND ANSWERS
1. REQUIREMENTS
a. Completion of 2 quarters at SBU (Full-time)
b. The scholarship award is based on the following:
1. Completed all requirements for entering Observation Phase of the Clinic Internship as a full-time student at
the University.
2. Earned a Cumulative Quarter Grade Point Average (CGPA) of 3.5 or higher.
3. Recommended by the Clinic Supervisors.
4. Dressed professionally and appropriately at all times.
5. Complied with Clinic Rules & Regulations, including prerequisites, CNT, HIPAA, & OSHA.
6. Actively recruited patients for the SBU Clinics.
7. Involved and collaborated in activities and/or services to fellow interns, the University, and the AOM
profession.
8. Demonstrated a genuine need for nancial assistance.
9. Enrolled in 120 or more internship hours for the quarter in which this scholarship is awarded.
2. HOW MANY TIMES CAN A STUDENT APPLY FOR AN CLINIC SCHOLARSHIP?
A student may not apply more than 3 times during a student’s academic studies in the MSAOM degree program.
Qualied interns may not receive more than two (2) scholarships during their tenure at the University.
3. WHAT IS THE TIME PERIOD?
It is for 1 quarter.
4. HOW MANY CLINIC SCHOLARSHIPS ARE GIVEN EACH QUARTER?
Three clinic scholarships are awarded per quarter, per campus.
5. WHAT IS THE SCHOLARSHIP AMOUNT?
The amount is $400.
6. APPLICATION PROCEDURE
a. Complete the scholarship request form.
b. Turn it in to the clinic director by the end of the quarter.
7. NOTIFICATION
Recipients will be notied by email during the 1st week of the following quarter.
SCR-C
Revised 2/10/2020
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Completed 16 July 2020

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