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.
|