KENTUCKY PUBLIC HEALTH ASSOCIATION
THEODORE “TED” HANEKAMP SCHOLARSHIP FUND
Name
Telephone
Permanent Address
You are automatically ineligible if you do not answer all questions.
1. Are you currently a member of KPHA?
2. What is your emphasis of study in Graduate School? ____________
3. Please write your estimated combined household income level. Detail any other
financial assistance you receive.
4. What is your Undergraduate Grade Point Average ?
5. Do you now or have you ever worked as a volunteer or served in a community service
capacity (even if part of high school activities)?
Yes
No
If NO; skip to question #9.
6. Please give name, address, phone number and dates of volunteer or community
service. Please be sure to include the type of service you performed.
7. Will you receive financial support from a parent, guardian or any other person or
organization?
Yes
No . If no, skip to question 13.
8. What other financial assistance will you be receiving in the grant year? Please
provide a list with the amount of monies granted.
9. How long have you lived in Kentucky?
10. Please write the name of the University you achieved your Undergraduate degree
from, town and state, and year of graduation.
11. Have you ever been awarded any other scholarships offered through the Kentucky
Public Health Association?
Yes
No
12. Please attach 3 letters of support or recommendation. (These can be from your
minister, teacher, counselor, community person or mentor).
13. Please provide a short summary of your career goals (future plans, what do you plan
to do?) Why do you feel that you deserve this scholarship? (You may attach additional
pages if needed).
I give my permission to the Kentucky Public Health Association to obtain information
from my educational institution. I also understand that the Kentucky Public Health
Association may contact any verifications listed.
Student’s signature________________________________ Date_____________
Note: APPLICATIONS WITHOUT A TRANSCRIPT AND / OR WITH
UNANSWERED QUESTIONS WILL BE INELIGIBLE.
THANK YOU FOR APPLYING!
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© 2014 Kentucky Public Health Association, Inc.