Scholarship Application Form

Riverside County Physicians Memorial Foundation
3993 Jurupa Avenue
Riverside California 92506
951-686-3343
FAX# 951-686-1692

*** APPLICATION FOR SCHOLARSHIP ASSISTANCE ***

This form may be downloaded to your printer and submitted via fax or regular mail. You may also request this application be sent to you by contacting Jeanne Vale at the Riverside County Medical Association.

Date:_____________________________________

Name:_________________________________________________________

Current Address:_________________________________________________

__________________________________________________

Current Phone#:_________________________

Date of Birth:_______________________________

Place of Birth:______________________________

Riverside County Resident:__________(years)_____________(months)

Sex:______________Age:_______________Marital Status:_______________

Citizenship:_________________________

Parent(s) Name:__________________________________________________

Parent(s) Address:_______________________________________________

________________________________________________

Parent(s) Phone#:___________________________________

Number of Siblings in your Family:________________

Ages:________________________________________________

To what school(s) have you been accepted?
What school do you plan to attend?

__________________________________________________________________________

Approximate Grade Point Average:_______________

Give a clear picture of your financial position. Indicate what percentage of support you can count on from any and all sources (parents, school, etc.). What amount of aid would you require and for how long?

__________________________________________________________________________

List Interests, extracurricular activities, honors won:

__________________________________________________________________________

Names, addresses, and phone numbers of two character references. One reference should be a Riverside County Physician or one of your professors in undergraduate training___________________________________________________________________

_________________________________________________________________________

Write a short statement on a separate sheet of paper stating your reasons for wanting to study medicine. You may wish to include your Association of American Medical Colleges Application Form.

Please include a current picture of yourself.

__________________________________________Signature