Pat & Frank Dawson 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

Are you attending school now?

Yes

No

School Now Attending

Location

Last School Attended

Location

GPA, SAT scores or present class standing

UVA Medical Center Junior Volunteer Program

During what years were you active in the JV Program?

Number of volunteer hours

In what services/area did you volunteer? Be specific about the responsibilities and what you learned.

Financial Assistance

I need financial assistance to pursue a health career for the following reasons:

Awards & Activities

List your academic awards, honors, membership activities, and community service:

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.

By submitting this form, you agree to our privacy policy.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.