CONTACT INFORMATION:

Name(Required)

First Last

Birth Date(Required)

Address(Required)

Date(Required)

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Name of Parent(s) or Guardian(s)(Required)

Current School of Enrollment(Required)

Expected Graduation Date(Required)

Are you currently or have you been an employee or volunteer of LifeCare?(Required)

OTHER INFORMATION

Please type thorough/narrative answers to the following questions below in essay format for each question. Each box has unlimited space for your response.

What post-secondary educational school do you plan to attend? Have you been accepted?(Required)

What type of health care career have you chosen to pursue?(Required)

Why have you targeted healthcare as a career track?(Required)

Have you ever worked, volunteered or had personal experience in a health-related field? Explain how this has impacted your life and your decision to pursue a health-related career.(Required)

What extra curricular or community activities have you been involved in?(Required)

Other comments?

Letter of Recommendation(Required)

Please insert a letter of recommendation from a teacher or member of the community who is not a family member. This letter should point out personal attributes that make you a good candidate for this scholarship.

Max. file size: 50 MB.

High School Transcript(Required)

Please attach a copy of your current high school transcript.

Max. file size: 50 MB.

If I am selected, I give LifeCare permission to publicize award information and photos for marketing purposes.

I understand that I must provide LifeCare Medical Center with proof of attendance and successful completion of the first semester of post secondary education and enrollment in a second semester, before the scholarship will be distributed.

Signature(Required)

Date(Required)

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