Auxiliary Health Care Career
Scholarship Application

  • 1. Personal Information

  • 2. Current Education

  • 3. Past Education

  • School NameStart DateGraduation DateSchool Address 
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  • School NameStart DateEnd Date 
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  • 4. Future Education

  • Name of SchoolField of StudyFor a Degree or Certificate In 
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  • Name of ProgramSchool of Program 
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  • Name of ProgramSchool of Program 
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  • 5. References (Unrelated to Applicant)

  • Reference 1
  • Reference 2
  • 6. Estimated Educational Expenses for 1 Year

  • Expense CategoryExpense Amount: 
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  • 7. Uploads / Attachments

  • *This may include present & future career goals, any special circumstances which may have influenced ability to continue or complete education.
  • 8. Agreement & Signature

    This application and supporting information becomes the property of Western Missouri Medical Center Auxiliary. I certify the information I have furnished is accurate and complete to the best of my knowledge and understand that it may be subject to verification with former employers and other persons. I authorize my past and present employers to supply any information they have concerning me or my work performance during my association with them and release them from all liability in connection therewith. I understand and agree that misrepresentation, falsification, or omission may be considered sufficient cause for rejection. I understand that this award may be taxable in the United States (see IRS tax code for information).