HAMA
Hispanic American Medical Association of Mercer County
SCHOLARSHIP APPLICATION
FULL NAME______SEX: MALE_____ FEMALE_____
OTHER NAMES (MAIDEN, ALIAS, DIVORCED, ETC) ______DATE OF BIRTH______
STREET ADDRESS______
CITY______STATE______ZIP CODE______
HOME PHONE______CELL PHONE______
WORK PHONE______Can you be contacted at work? YES______NO______
E-MAIL ADDRESS______
RACE: LATINO_____ OTHER _____ COUNTRY OF BIRTH: ______
GROUP AFFILIATION(S) (ie Sorority, Fraternity, Community Groups)______
VOLUNTEER EXPERIENCE: □ YES □NO ORGANIZATION NAMES: ______
Please Attach Resume if Available
YEARS OF EDUCATION______CURRENT/LAST SCHOOL ATTENDED______
MARITAL STATUS: MARRIED_____ SINGLE_____ DIVORCED_____ SEPARATED______WIDOWED ____
SPOUSE’S NAME (if applicable) AND OCCUPATION ______
IF YOU HAVE CHILDREN, LIST THEIR NAMES AND AGES: ______
ESTIMATED ANNNUAL INCOME: ______
CAREER OR AREA OF STUDY OF INTEREST: ______
Please Attach a Personal Essay Statement About Your Career Goals
(Minimum 4 paragraphs)
EMPLOYMENT INFORMATION
YOUR OCCUPATION ______
EMPLOYER’S NAME ______
STREET ADDRESS______
CITY______STATE ______ZIP CODE ______
WORK HOURS______
REFERENCES (People who have known you for at least 1 year)
q EMPLOYER/SUPERVISOR ______
STREET ADDRESS ______
CITY ______STATE ______ZIP CODE ______
HOME PHONE______WORK PHONE ______
EMAIL ADDRESS______
q NEIGHBOR/COMMUNITY MEMBER ______
STREET ADDRESS ______
CITY______STATE ______ZIP CODE ______
HOME PHONE ______WORK PHONE ______
EMAIL ADDRESS______
q CAREER COUNSELOR/TEACHER______
STREET ADDRESS ______
CITY ______STATE ______ZIP CODE ______
HOME PHONE ______WORK PHONE ______
EMAIL ADDRESS______
How did you hear about our scholarship? ______
I certify that the above information is true and accurate to the best of my knowledge. I give my consent to HAMA of Mercer County to contact the above references to secure information on my character, reputation, and/or academic performance.
SIGNED______DATE ______
CONFIDENTIALITY POLICY
All records (including written, video, file, picture or use of prospective scholarship recipient’s name in organization publications are considered the property of HAMA and not the HAMA scholarship applicant. Information from outside sources, including confidential references, must be assessed along with information gained from the prospective student scholarship recipients themselves. Records are not available for review by the prospective scholarship recipient. Records are kept in areas that are only accessible to the organization’s staff and aren’t available for review by the parents, relatives, friends and/or any other individual not designated by HAMA.
The organization respects the confidentiality of scholarship recipients/volunteers and shares information about the scholarship recipient/volunteer only among the organization’s members with the exception of situations listed below:
1. Information will be released to other individuals or organizations only upon request (written or oral) of the scholarship recipient.
2. Identifying information regarding scholarship recipients may be used in organization publications or promotional materials if the scholarship recipient has given permission by signing this form.
3. For purposes of program evaluation, audit, or accreditation, and with the prior approval of the Board of Directors, certain outside bodies may have access to scholarship applicant records. These outside organizations shall be required to respect the organizational policy on confidentiality. Outside parties shall be required to use information only for the purpose(s) stated in the approval action of the Board of Directors.
4. Members of the Board of Directors have access to student files only upon authorization by formal motion of the Board of Directors. The motion shall state who shall be authorized to review records, the specific purpose for such review and the period of time during which access shall be granted. HAMA members shall be required to comply with HAMA policies on confidentiality and may use the information only for purposes stated by the approved action of the Board of Directors.
I have read and understand the above document that states HAMA policy with respect to confidentiality of scholarship applicant records. I agree to scholarship program participation under the conditions it sets forth.
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Signature of Scholarship Applicant Date
RELEASE AND AUTHORIZATION
RELEASE AND AUTHORIZE
I voluntarily and knowingly, for scholarship application purposes only give permission to institution of learning, law enforcement agency, state agency, federal agency, consumer reporting agency, employer, military branch, personal reference and/or other persons to give records or information they have concerning my general reputation, character, academic performance or any other information requested by HAMA. I voluntarily and knowingly unconditionally release any named or unnamed informant from any and all liability resulting from the furnishing of this information. An e-mailed, photographic, or faxed copy of the authorization shall be valid as the original. HAMA reserves the right to conduct annual reviews as deemed necessary. I also give permission for HAMA to use my name in news articles and for my photo to be taken and used for publicity purposes and/or for submission to funders.
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Full Name (Type or Print Legibly)
______
Other Names Used: (Maiden, Divorced, Alias, Etc.)
______
I certify that the information on this application is true and correct and I understand that falsification is grounds for denial of scholarship opportunity.
Full Name (print): ______
______
Signature Date
Enclosure: Please check items enclosed
□ Resume (if available)
□ Official School Transcripts
□ Current Year Tax Forms
□ Personal Career Goals Essay Statement
HAMA BOARD OF DIRECTORS REVIEW ONLY
SCHOLARSHIP GRANTED: ______TERM/YEAR: ______SCHOLARSHIP NOT GRANTED:______
SCHOLARSHIP AMOUNT APPROVED: ______CAREER PATH CHOSEN: ______
COMMENTS: RUBRIC TOTAL SCORE: ______
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BOARD MEMBER APPROVAL DATE
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