MI PA Foundation


		Application for the Michigan PA Foundation Annual Scholarship Award. Version 4.1, February 26, 2012. *Qualifications:* Must be a physician assistant student in their final clinical year currently enrolled in a PA Program in Michigan as of August 1, 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 whaterver you believe to pertain: Prior or current research, independent and organizational initiated volunteer activities and programs. Requirements: Completed Scholarship Applications must be received by August 1, 2012, which includes the verification of a physician assistant senior student status by the PA program director. *Submission Information* 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 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 email to Dr. Deuben. 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 Jack as given above. *Notification* Scholarship Award recipients will be contacted by September 20, 2012. Formal Award presentation will be made at the Annual Fall Michigan Academy of Physician Assistants CME Conference, October 12, 2012, Friday. The 2012 MAPA Conference is at Soaring Eagle Conference Center in Mt. Pleasant, Michigan. 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 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 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.
		------------------------------------------------------------ The Michigan PA Foundation Scholarship Application 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 May 1, 2012, Submission of this form: August 1, 2012, Submission of Program Directors Section: August 1, 2012, Notification of Scholarship Grant to applicants: September 20, 2012, Scholarship Award given at Student Challenage Bowl, MAPA Conference, Friday October 12, 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* (Student Loans are not counted.) Current Employer, if any: Position Expected Annual Income from employment Amount of grants/scholarships for junior year Amount of grants/scholarships expected for senior year Financial support from other sources Total annual income for 2010: *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 email 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: 25% Scholarship: 25% Professional Involvement and Community service: 50% 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. ....................................................................................................