Scholarship Application

Med Leaders_Oval

PARTIAL SCHOLARSHIP APPLICATION

for

Student Name: __________________________________

Student Invitation Number: _________________________

To apply for a partial scholarship of $450, students’ families must first attest to financial need. Students must also provide two teachers for the Academy to contact to provide recommendations.

This application MUST:

  • be completed in full to be considered.
  • be completed and returned to the Academy by one week before the student’s enrollment deadline. Any applications submitted after this date will not be considered. Students should not enroll until a decision has been made regarding scholarship approval.
  • include a notarized Parent Certificate of Need. Do not send federal tax papers unless they are explicitly requested by the Academy.
  • be sent as a digital copy of this document to Application@FutureDocs.com or fax to (888) 453-6660. Do not mail forms to the Academy.  (Please do not send any other correspondence to Application@FutureDocs.com.)

NOTE: Do not enroll in the Congress until you have a determination on your Scholarship. Scholarship Applications will not be considered for enrolled students.

 

1. PARENT/GUARDIAN CERTIFICATION OF NEED:

I, as the parent/guardian of the student listed above, swear or affirm, under penalty of perjury and subject to verification, that my household lacks the financial means necessary to pay the full cost of tuition for my child to attend the Congress of Future Medical Leaders being held in June 2016 in Lowell, MA.

I agree, within seven (7) days of separate written request from the National Academies, to supply my personal federal tax returns for 2014 and 2013, including all W-2s and schedules. If self-employed, I agree to supply the Academies with copies of my federal business tax returns for 2014 and 2013, including all schedules. I understand that these documents are not being requested at this time.

I also authorize the National Academies to order a credit report on me.

_________________________________________     _________________________________________
Signature of Parent/Guardian       Date
_________________________________________      
Printed Name of Parent/Guardian      
_________________________________________     _________________________________________
Street Address         City, State, Zip
_________________________________________     _________________________________________
Parent/Guardian Phone Number     Parent/Guardian Email Address

 

 

 

[Notarization here]

 

 

 

 

 

2. TEACHER/EDUCATOR CERTIFICATION (ONE):

I declare that, to the best of my knowledge and belief, the student listed above has a GPA of 3.5 or better, either current or cumulative. I authorize the Academies to contact me by phone, email, or fax to verify this statement if necessary.

_________________________________________     _________________________________________
Print Name (Mr./Ms./Mrs.) First Last     Signature
_________________________________________      _________________________________________
Teacher Title      Date
_________________________________________     _________________________________________
School Name         Teacher Email Address

 

3. TEACHER/EDUCATOR CERTIFICATION (TWO):

I declare that, to the best of my knowledge and belief, the student listed above has a GPA of 3.5, either current or cumulative. I authorize the Academies to contact me by phone, email, or fax to verify this statement if necessary.

_________________________________________     _________________________________________
Print Name (Mr./Ms./Mrs.) First Last     Signature
_________________________________________      _________________________________________
Teacher Title      Date
_________________________________________     _________________________________________
School Name         Teacher Email Address

 

 

4. STUDENT CERTIFICATION

I, as a prospecting Delegate to the Congress of Future Medical Leaders, declare that the details furnished above are true and correct to the best of my knowledge and belief. I understand that in the event any of the above information is found to be false, untrue, misleading or misrepresenting, my application will be rejected.

_________________________________________     _________________________________________
Signature of Student     Date
_________________________________________      _________________________________________
Student Mobile Phone      Student Home Phone
_________________________________________  
Student Email Address