Application
for the
Michigan PA Foundation
Annual Scholarship Award.
Version 2.8, May 17, 2009.
Qualifications:
Must be a physician
assistant student in their final clinical year currently enrolled in a
PA Program in Michigan as of August 1, 2009.
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.
Requirements:
Completed Scholarship Applications must be received by August 1, 2009, which includes the verification of a physician assistant senior student status by the PA program director.
Notification
Scholarship Award recipients will be contacted by September 8, 2009. Formal Award presentation will be made at the Annual Fall Michigan Academy of Physician Assistants CME Conference at the Boyne Mountain Resort, Boyne Falls, Michigan, October 9, 2009. The presence of the award recipients at the Award Ceremony and permission for photographs is requested.
Submission Information
There are two methods available to complete this Application.
The first is to complete the form, print this page, and mail it by the USPS to Dr.Caroll Deuben, 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 email to Dr. Deuben. Completed applications should be mailed to:
Caroll Deuben, Ph.D.
Chair, Scholarship Selection Committee
Michigan Physician Assistant Foundation
759 Grand Marais
Grosse Pointe Park, MI 48230
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 Dr. Deuben at deuben@att.net. 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 Dr. Deubenl or print the Program Director section and mail it to Caroll.
Privacy Information: Our Promise to you.
We consider the information you provide to be privileged and confidential. Only the Scholarship Application Review Committee will see your 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.
The Foundation reserves the right to use your name as a recipient of the Scholarship Award. Should you be selected, 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 use your comments in promotional material in fund raising activities.
The section below is to be completed by your Program Director, as given in the instructions above.
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
Thank you. Your suggestions for improvement of this form and the process used are welcome.
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