Liz Courain Madison House Graduate Degree Scholarship Application

School of Acceptance

Academic Year

School

Address

City/Town

State/Province

ZIP/Postal Code

I intend to pursue a health career in the field of

I certify I have been accepted for admission at this time

Yes

No

Demographic Information

First

Middle

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone Number

Place of Birth

Date of Birth

Gender

Marital Status

Are you presently employed, if so where?

Email Address

I am a citizen of the US or a permanent resident

Yes

No

Previous School Information

Year of UVA Graduation

Degree Received

GPA and present class standing

Future Goals

What are your future goals after graduation from the health care degree program?

Participation in UVA Madison House Program

Please tell us about your experience as a Madison House volunteer at UVA Health System (what area(s) did you volunteer, what were your responsibilities, what lessons did you learn that will help you in your chosen health care career, how did this experience make a meaningful impact on your life/education/future).

Awards & Activities

List your extracurricular activities, hobbies, outside interests and community service:

Financial Assistance

List other financial assistance you will receive or have been awarded for this degree (scholarships, grants, financial aid, or other).

References

Reference #1

First

Last

Relationship/Role

Place of Work

Email

Phone Number

Reference #2

First

Last

Relationship/Role

Place of Work

Email

Phone Number

Please include information on two individuals who have agreed to write a recommendation for you. Do not use family, friends or Volunteer Services staff. We will contact your references via email.

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