The Michigan PA Foundation

 

Scholarship Application

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Application for the
Michigan PA Foundation 2012
Annual Scholarship Award.  

Version 5.0, October 16, 2011.    

Qualifications:

Must be a physician assistant student in their final clinical year currently enrolled in a PA Program in Michigan as of August 31, 2012.

Must exhibit one or more of the following:
1. Financial Need,
2. Outstanding scholarship,
2. Professional involvement, and/or
3. Community service,

Financial need means that which may impact on the student's ability to concentrate on academic requirements for successful completion of physician assistant training. Professional involvement / Community Service can be whatever you believe to pertain: Prior or current research, independent and organizational initiated volunteer activities and programs.

Submission Information

Completed Scholarship Applications may be submitted after April 1, 2012, and must be received by August 1, 2012. These submission guidelines includes the verification of information by the PA program director. Exceptions to this policy may be granted by the Scholarship Committee upon request for consideration.

There are two methods available to complete this Application.

1. The first is to complete the form, print this page, and mail it by the USPS to Mr. Jack Kircher, as given below. Your Program Director (or their representative) must complete the Program Director Verification of Student Status section at the end of this form and mail or e-mail Mr. Kircher. Completed applications should be mailed to:

Jack Kircher, PA-C
Scholarship Committee Chair
905 Cecelia Court
Essexville, MI 48732-2102

2. The second method available to submit this form again requires your completion of each section in the form. Then copy the form and paste into an e-mail to Mr. Kircher at jkircherpa@aol.com. You will then need to ask your Program Director to complete the Program Director Verification of Student Status section below, copy and paste in an e-mail to Jack or print the Program Director section and mail it to Mr. Kircher as given above.

Notification

Scholarship Award recipients will be contacted by September 9, 2012. Formal Award presentation will be made at the Annual Fall Michigan Academy of Physician Assistants CME Conference, Friday evening, October 15, 2012 during the Student Challenge Bowl. The presence of the award recipients at the Award Ceremony and permission for photographs is requested.

Privacy Information: Our Promise to you.

We consider the information on the Scholarship Application you provide to be privileged and confidential. Only the Scholarship Application Review Committee will see your submission information. Particulars will not be shared with other Foundation Board of Directors members or outside parties. It will never be sold, bartered or released to any third parties, including your classmates or PA Program Personnel.

Legal Issues

Should we determine that you provided false information on your application, the Foundation will request the Award be returned to us. We will pursue legal avenues should difficulties arise.

Your application will be reviewed by at least three reviewers, with at least two of them being graduate PAs. Reviewers score will be averaged, with award given for the highest score for each program. This decision is final. Applications will be destroyed after final determination is reached, and no paper or electronic storage of personal information will occur.

The Foundation reserves the right to use your name as a recipient of the Scholarship Award during the Award Presentation, in promotional materials, and to media outlets. Should you be selected to receive an Award, we will ask you to provide a short comment on how the Award was helpful to you in continuing or completing your PA education. We also reserve the right to also use these comments in promotional material in fund raising activities.

 

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The Michigan PA Foundation 2012 Scholarship Application

    The Foundation We are seeking to know about your unique situation, and why your personal circumstances are more compelling than others. Please review the submission guidelines given above before sending.

Here are the timelines:
Applications accepted after April 1, 2012,
Submission of this form: August 1, 2012,
Submission of Program Directors Section: August 1, 2012,
Notification of Scholarship Grant to applicants: September 9, 2012,
Scholarship Award given at MAPA Fall Conference Student Challenge Bowl, Friday 2012.

Biographical Data

Michigan PA Program:
    CMU   GVSV   UDM   WMU   WSU

Name    
Address
Evening Telephone with Area Code
Alternate Telephone or pager
Relationship Status Married Single
On what day will / did you enter your final year / half of your PA Program?
Your expected date of graduation
Current Grade Point Average

Financial Resources
Current Employer, if any  
Position
Expected Annual Income from employment for 2011 
Expected Annual Total Household Income for 2011  
Amount of grants/scholarships for junior year  
Amount of grants/scholarships expected for senior year
Financial support from other sources for 2011 
Total annual income from all sources for 2011:  

Professional Membership
 Current AAPA member/fellow?    Yes No

Current MAPA member/fellow?   Yes No

(Please provide details in your Narrative if your answer was no to either question)

Narrative

In a brief narration as an attachment (either as additional information in your e-mail submission, or as a separate paper should the application be sent as a U.S. Postal Service submission), discuss the following points:

~ Your past, present, and future plans to serve in volunteer work,
~ Your involvement in activities sponsored by student professional academies/organizations,
~ Your involvement in Student PA research,
~ Academic honors, awards, or special recognition that you have received (Dean's List and other scholarship achievement awards such as cum laude, magna cum laude, summa cum laude, etc.),
~ Other honors, awards, or special recognition that you have received,
~ Comments on your academic record, and
~ Your financial needs.

Scholarship Criteria

Our criteria for judging applications for a scholarship grant is:

Financial need: 50%
Scholarship: 20%
Professional Involvement and Community service: 20%
Reviewer's Holistic Evaluation of the Application: 10%

 

The section below is to be completed by your Program Director, as given in the instructions above.

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Program Director Verification of Student Status


The student, _____________________________________________________,
is currently enrolled and is in good standing in our Physician Assistant Program.
The grade point average and graduation date given in the application above
is correct.

_________________________________________________________________
Printed Program Directors Name                                                   Institution

_________________________________________________________________
Signature                                                                                  Today's Date

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Thank you. Your suggestions for improvement of this form and the process used are welcome. Please forward suggestions to Mr. Jack Kircher, PA-C.

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