2007-2008 Physician Assistant Foundation Scholarship Application
[ Application Instructions ]    [ 2007-2008 Physician Assistant Foundation Scholarship Application ]

APPLICATION INSTRUCTIONS [ top ]

Applicants may complete this application in one of the following two ways:

  1. Type your answers directly into the spaces provided on the Web page and print out the completed form.
    • When you've completed the form, click on the 'FORMAT FOR PRINTING' button at the bottom of the page. This will create a printable copy of the form that you have completed.
      *ATTENTION* Clicking on the 'Clear Form' button will erase all your responses from the form.
    • Print out the completed form and mail it to the PA Foundation office as part of the application package described below.
      *ATTENTION*This form CANNOT be submitted on line.

  2. Type your answers on a separate sheet of paper and attach them to the application.
    ( NOTE: Please be sure to include both the number of the question and the question itself before your typewritten answer. )

Dear PA Student:

The Physician Assistant Foundation has awarded more than 750 scholarships totaling more than $1,000,000 to deserving PA students. Any student member of the American Academy of Physician Assistants who is attending an ARC-PA-accredited PA program and is in the professional phase of his or her program is eligible to apply. Scholarships are awarded based on the availability of funds provided through contributions from AAPA members, individuals, and corporations. Previous PA Foundation scholarship recipients are NOT eligible to apply.

This application form provides the PA Foundation Scholarship Committee with important information. Please read each question carefully and answer each question fully. It is imperative that you meet the established January 15 deadline. INCOMPLETE APPLICATIONS ARE INELIGIBLE FOR REVIEW.

Applications will be reviewed and judged on the basis of financial need, academic record, community and professional activities, and future goals as a physician assistant. You will be notified in May 2008 of the Scholarship Committee's decision. All monies awarded will be distributed in May 2008, and all recipients will be recognized in published format at the AAPA's 36th Annual PA Conference in San Antonio, TX.

If you have any questions regarding this application or the scholarship program in general, please contact the Foundation at 703/519-5686

Best of luck as you continue your studies

Kent W. Wallace, PA-C
PA Foundation President
S T O P

Before proceeding, complete the following eligibility checklist. You must answer yes to each criteria to qualify for this program.
AAPA Member (or applicant)
(Click here for application form)		 Currently attending a ARC-PA-accredited PA program (consult your program director if you are unsure)
Able to submit PA program grades with this application I have NOT received a PA Foundation scholarship before
I am in the professional phase of PA training (pre-PA program or pre-PA phase training not eligible)

INSTRUCTIONS - Please read carefully.

  1. Answers and information in each part of this application must be computer-generated. Handwritten and/or incomplete applications will not be accepted. ONCE SUBMITTED, APPLICATIONS MAY NOT BE CHANGED OR REVISED.

    DO NOT include additional sheets except where requested. (Any additional unsolicited information will NOT be forwarded to the Scholarship Committee.) DO NOT change the format of this application. Please collate and staple application materials (original plus two copies).

    All application materials must be postmarked by January 15, 2008, and sent to the PA Foundation Scholarship Committee, 950 North Washington Street, Alexandria, VA 22314-1552.

  2. Your application package must include THREE copies (original and two copies):
    • The signed application Your most recent cumulative PA program G.P.A. (See Parts II & III) Letter from the financial aid office at your program verifying your financial assistance status Copy of the Standard Student Budget (See Part IV). Information from the financial aid office must coincide with information given in Part IV: Financial Information.
    • Two passport-style photos of yourself suitable for publication. Please put these photos in a separate sealed envelope with your name printed on the back of each photo as well as on the front of the envelope. No photos will be released to the Scholarship Review Committee. Envelopes containing photos of those students selected as scholarship recipients will be opened only after the selection process is finished for use in scholarship publicity materials.

APPLICATIONS MUST BE POSTMARKED BY JANUARY 15 - DON'T JUST MEET THE DEADLINE, BEAT THE DEADLINE!

PART I: Personal Information

First Name
Middle Name
Last Name
Social Security Number
Address to which all correspondence should be sent; If this changes during the application process, notify the PA Foundation Immediately.
City, State and Zip
Daytime Telephone
ARC-PA-Accredited PA Program Attending
Graduation Date

 Applying for AAPA Student Membership at this time. The membership application form included with this application is complete and my dues payment is attached.

 Current AAPA member.
Membership number is (AAPA membership is required.)


PART II: PA Program Director Reference (NOTE: Director may appoint designee.)

I hereby certify that the above applicant is enrolled in our program as stated in this application, is in good academic standing, and has a cumulative G.P.A. as a PA student as listed below.
PA Program
PA student cumulative G.P.A.
G.P.A. SUBMITTED MUST COINCIDE WITH OFFICIAL TRANSCRIPT

 

_____________________________________________________________________________________________
PA Program Director/Designee Signature

PART III: Academic History

Include your cumulative PA program grades. If an official transcript is unavailable, a printed grade report signed by your program director is acceptable. Only PA program grades will be accepted. Under Part II above, your program director MUST write in your cumulative G.P.A. for your PA program grades only.

PART IV: Financial Information - Please provide the following information for the 2007-2008 academic year.

[ *ATTENTION: This table DOES NOT calculate the numbers entered. You must enter the correct numbers and totals manually ]

2007/2008 Financial Contributions
a)Your contribution for 2007/2008 expenses available from:
 Salary/wages (yours) $
 Savings (yours) $
 Spouse (contribution to school) $
 Family/Gifts $
b) Tuition Assistance* (see below)
 Grants $
 Scholarships $
 Loans $
c) Other Available Financial Resources $
2007/2008 Expenses
PA Program Expenses 2007/2008
(12 months only):
 1) Tuition $
 2) Books, Supplies, Fees $
 3) Program-Related Transportation $
 4) Room & Board $
 5) Medical Insurance $


* MUST MATCH PA SCHOOL STANDARD STUDENT BUDGET
(Sum of A-C)
  Financial Contribution (2007/2008)		 $
(Sum of 1-5)
  Your Expenses (2007/2008)		 $
  • Applicant must attach a letter from the financial aid office at your program verifying all tuition assistance you currently receive and a copy of the Standard Student Budget. If you do not receive assistance of any kind, please have the office confirm this in the letter. This letter MUST coincide with tuition assistance In above Financial Contributions Section. Personal loans must have written affidavit.
PART V: Community and Volunteer Professional Services

Identify your active involvement in volunteer activities in school, in the community, and in the profession DURING your PA education. Preprogram mentoring/shadowing and/or paid activities are not eligible. Be brief.

Activity
Example: Health Fair

 Role/Responsibilities
Example: Manned the booth

 Time Commitment per month
Example: 3 hours per month


PART VI: Issues in Health Care

Please keep answers brief.
Creatively discuss at least two of the most important health care concerns in the population in your community (250 words or less)



Part VII: Professional/Personal Statement

A. Present a specific example of how you would contribute to resolving one of the health care concerns listed above. (250 words or less)


B. If you have any specific clinical interests, what impact would you hope to have over the first several years of your clinical practice? (250 words or less)

 

Your application must include THREE COPIES, one of which must be an original:

The signed application

Your most recent PA program transcript or grade report

Letter from the financial aid office at your program verifying your financial assistance status

Copy of the Standard Student Budget (See Part IV.)  Information from the financial aid office must coincide with the information given in Part IV: Financial Information

Two passport-style photos of yourself suitable for publication.  Please put these photos in a sealed envelope with your name printed on the back of each photo as well as on the front of the envelope.  No photos will be released to the Scholarship Review Committee. Envelopes containing photos of those studetns selected as scholarship recipients will be opened only after the selection process is finished for use in scholarship publicity materials.

I understand that if the application is not complete, it will be ineligible for judging. I attest that the contents of this scholarship application are true and accurate. I understand that a corporate scholarship sponsor may request a copy of this completed application form. I also agree that if I receive a scholarship, my photograph and any correspondence may be published in AAPA/PA Foundation publications. Finally, I understand that all judging is final.

_____________________________________________________________________________________
Signature of Applicant Date
 


FOR OFFICE USE ONLY:   Postmark Date:______   Application Typed:______   School Budget:______
AAPA______   ACCRED______   LETTER______   GRADES______   PHOTOS______   DIRECT______   SIGN_____


HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTED!
     

 

 

Last Revised: 6/28/07