Southwestern Medical Clinic Foundation Scholarship Application

Complete this application AFTER you have carefully read the scholarship information web page, to make sure you qualify. This application and all references must be submitted and received at least 90 days prior to the start date of your trip.

First Name*

Last Name*

Mobile Phone*

Home Phone

Email Address*

Address*

City*

State or Province*

Zip or Postal Code*

Country

Birthdate*

EDUCATION

College - Undergraduate

Name of school

Degree

City

State

Dates Attended

Graduation Date

Medical or APP School

Name of school

Degree

City

State

Dates Attended

(Expected) Graduation Date

Residency Location

Name of hospital

Specialty

City

State

Dates Attended

Expected Completion Date

PROPOSAL FOR SHORT-TERM MEDICAL MISSION WORK

Name of Hospital

City

State

Country

Intended Dates of Service

Goals for Mission Trip

Name of Affiliated Church or Mission Organization

MEDICAL MISSION TRIP COSTS

Airfare

Visa

In Country (housing, food, etc.)

Other

Specify below.

Please specify "other" costs here

Total Estimated Costs

Other Trip Funding Sources and Amounts

Amount of Trip Costs Still Needed

SPIRITUAL INFORMATION

Please tell us about your relationship with God