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Sherr-scholarship-application-form - Sherr Scholarship Application

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1


Sam&RosemarySherrDean’sExcellence
Scholarship/FellowshipApplication
2019‐2020
ApplicationInstructions:
1. FORALLSCHOLARSHIPS/FELLOWSHIPS,youmustbeadmittedtoaCollegeof
HealthProfessionsprofessionalprogramANDhaveaminimumcumulative
GPAof3.0.Aninterviewmayberequestedaspartoftheselectionprocess.
2. Completethestudentdatasectionoftheapplication.
3. Completethefinancialaidinformationsectionoftheapplicationifyouwishto
beconsideredforneed‐basedscholarships/fellowships.FAFSAinformation
needstobeonfilewiththeWSUFinancialAidOffice.
4. AttachaTYPEDonepagepersonalstatement.Youmayuseyourstatementto
highlightyourspecialinterests,talents,goalsoruniqueexperiences.Please
includelongrangegoals.Thepersonalstatementallowsyoutoprovide
additionalinformationforconsiderationbythescholarship/fellowship
committee.
5. Attachanactivitieschart(samplebelow)includingyouracademic,leadership,
extracurricular,campus,communityservice,andworkexperiences.Witheach
activity,providethedatesyouwereinvolved,timecommitmentsandany
leadershiprolesyouhad.
6. Pleaseattachtwoprofessional/personalreferencelettertothisapplication.
7. ThisapplicationisfortheSam&RosemarySherrDean’sExcellenceAwardfor
studentintheprofessionalCHPprogramsofMedicalLaboratorySciences,
PublicHealthSciences,DentalHygiene,PhysicalTherapy,PhysicianAssistant,
CommunicationSciences&Disorders,andNursing.
8. PleasereturncompletedapplicationstoyourCHP
DepartmentbyThursday,Nov.1
st
2018.
2
STUDENTDATA:
Name_______________________________________________________________________________
First Middle Last Maidenorother
WSUID______________________________________________
DateofBirth(dd/mm/yyyy)________________________ Female Male
MailingAddress_______________________________________________________________________
City___________________State________________Zip______________

Phone(____)______________________
E‐mailAddress_____________________
AcademicMajor_____________  AnticipatedGraduationDate________
CumulativeGPA(Undergraduate)__________CumulativeGPA(Graduate)__________
Theinformationbelowisusedonlytodetermineyoureligibilityforspecificscholarships/fellowships.
Expectedenrollment(#ofcredithours)atWSUduring:Fall2019_____Spring2020_______
AreyouaU.S.citizenorPermanentResident?Yes No
Areyoucurrentlyemployed? YesNo Hoursperweek_________

Iactivelyparticipateincommunityactivities(volunteerwork,churchinvolvement).
YesNo

If“yes”attachadetailedlistofyouractivitiesspecificallythosecommunityservicerelated.
3
FINANCIALAIDINFORMATION(optional):Allfinancialinformationwillbekeptconfidential.Thissection
isoptionalbutmustbecompletedalongwiththeFAFSAifyouwishtobeconsideredforneed‐based
scholarships.
FINANCIALSTATEMENT(optional):Ifyoufeelthefinancialinformationenteredaboveandonyour
FAFSAdoesnotfullyreflectyourcurrenteconomicsituation,pleasecompleteafinancialstatementand
includeitwithyourapplication.Youmayincludeinformationregardingyouandyourfamily’sfinancial
statusthatsupportsyourneedforscholarships.TofillouttheFAFSAgotoFAFSA.ed.gov.
HaveyoufilledouttheFAFSA? YesNoIplanto

StudentCertificationandSubmission:Bycompletingandsubmittingthisapplicationforreview,Icertify
thatalltheanswersIhavegiveninthisapplicationarecorrecttothebestofmyknowledge.I
understandthatfailingtodiscloseorfalsifyinginformationcouldresultinmydismissalfromWichita
StateandthatmakingfalsewritingisafelonyunderKansaslaw(K.S.A.21‐3711).SocialSecuritynumber
andstudentstatusdatamaybeprovidedtootherstateagenciesforuseindetectionoffraudulentor
illegalclaimsagainststatemoneys.Igrantpermissiontoobtaininformationaboutmygradepoint
average,enrollmentstatusandfinancialstatustoevaluatemycandidacyforscholarshipawards.I
understandthisinformationwillbekeptconfidentialandwillbeavailableonlytoScholarship
Committeemembershavinganeedtoknowforthepurposeofscholarshipdetermination.IfIam
awardedascholarship,IauthorizetheUniversitytopublishmynameasascholarshiprecipient.
SignatureofApplicantDate
NoticeofNondiscrimination:WichitaStateUniversitydoesnotdiscriminateinitsprogramsand
activitiesonthebasisofrace,religion,color,nationalorigin,gender,age,maritalstatus,sexual
orientation,politicalaffiliation,statusasaveteran,geneticinformationordisability.Thefollowing
personhasbeendesignatedtohandleinquiriesregardingnondiscriminationpolicies:Director,Officeof
EqualEmploymentOpportunity,WichitaStateUniversity,1845Fairmount,Wichita,Kansas67260‐0145,
(316)978‐6791.
STUDENT:
__________ Estimated yearly gross income
Total number of dependents (not
__________ including yourself, spouse/partner)
Number of dependents who will be
__________ full-time college students in 2018-2019 AY
Yes No Has there been a significant change in your
financial status in the past year? If yes,
please include a “Financial Statement” with
your application. Instructions below.
PARENT(S) or GUARDIAN(S): (Dependent students only)
__________ Estimated yearly gross income
Total number of dependents (not
__________ including yourself, spouse/partner)
Number of dependents who will be
__________ full-time college students in 2018-2019 AY
Yes No Has there been a significant change in your
financial status in the past year? If yes,
please include a “Financial Statement” with
your application. Instructions below.
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Completed 27 February 2020

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