The Wayne F.Shovelin Scholarship
Personal Information:
First NameMiddle Name Last NamePreferred Name
Street AddressCityStateZip Code
Email AddressDate of BirthCell Phone (If Applicable)
Parent or Guardian Email AddressHome Telephone
Intended Major/Path of Study:
Have you ever been expelled or suspended from school?
If yes, please explain.
Have you ever been convicted of a crime?
School Information:
High School Name
Counselor Name (Reference #1)E-mailTelephone
Reference Name #2E-mailTelephone
Reference Name #3E-mailTelephone
Academic Achievement:
HIGHEST SAT:
Critical Reading Score/DateMath Score/DateWriting Score/Date
HIGHEST ACT:
English/DateMath/DateReading/DateScience/DateComposite/Date
Class Rank:out of GPA:
Weighted Unweighted
How many AP (Advanced Placement) courses are offered at your high school?
Below, list AP courses you have taken or are currently taking:
Does your school offer an International Baccalaureate curriculum?
Senior Year Courses:
SemesterCourse NameSemester Course Name
Is English the primary language spoken in your household?
Do you speak any other languages? Years studied/spoken
Which language(s)?
Significant Honors and Awards:Please list, in order of importance to you, any honors or awards you have receivedduring high school, both within and outside the classroom.
Honor/AwardDate ReceivedOrganization
Description
Honor/AwardDate ReceivedOrganization
Description
Honor/AwardDate ReceivedOrganization
Description
Honor/AwardDate ReceivedOrganization
Description
Honor/AwardDate ReceivedOrganization
Description
Extracurricular and Leadership Activities: Please list your primary extracurricular and leadership activities during high school, including summers, in order of their importance to you. Please place an asterisk (*) beside the three activities you wish to be given special consideration.
ActivityParticipation Date(s)Position Held
Please list any current and previous employment:
to
EmployerPositionDate Range
to
EmployerPositionDate Range
to
EmployerPositionDate Range
Community Service: Please summarize three noteworthy community service/volunteer experiences below, your motivation for service, the population served, and what you learnedfrom the experience.
Experience 1:
Experience 2:
Experience 3:
Essay Questions: Please attach a typed document with answers to the following essay questions. Please limit all responses to the word counts provided.
A. What exciting idea or experience from your recent studies or activities has sparked your interest? What have you done to explore this interest or how has it challenged you? (350 words)
B. What makes you a qualified applicant for the Shovelin Scholarship and how would the scholarship facilitate your pursuit of ahealthcare career? (350 words)
D. The Shovelin Scholarship includes summer internship opportunities. Describe in detail an ideal local healthcare-focused summer internship that you would create and complete the summer after your freshman year of college. (350 words)
E. Is there any additional information you feel is of importance to the selection committee but that you were unable to include?Limit responses to one paragraph.
In submitting this application, I authorize investigation of all statements contained in it, and it is understood and agreed that any misrepresentation by me in the application will be sufficient cause for cancellation of this application. I authorize the CaroMont Health Foundation to make any investigation deemed necessary and release the party contacted from all liabilities and damages for issuing same.
SignatureDate
Please mail the completed scholarship application packet to the following address:
CaroMont Health Foundation
Attn: Debbie Windley
RE: Shovelin Scholarship
2525 Court Drive
Gastonia, NC 28054
All scholarship application packets are due by noon on Tuesday,December 1, 2015.
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