SCHOLARSHIP
APPLICATION FORM
PAGE 1
Submit completed application to:
Office of the Registrar and Student Enrolment
The Michener Institute for Applied Health Sciences
Room 500
222 St Patrick Street, Toronto,
ON M5T 1V4
E-mail: scholars@michener.ca
PLEASE PRINT CLEARLY.
PERSONAL INFORMATION
Student Name
Surname
First Name
MICHENER ID
Expected Date of Graduation (mm/yy)
Semester Completed as of July 30th
Status in Canada
 Canadian Citizen
 Permanent Resident
 Study Permit
Marital status
 Single
 Married
 Other
 Other
CONTACT INFORMATION
Michener Email
Home Phone
Cell Phone
Mailing Address
Street
City
Apt/Unit No.
Province
Country
Postal Code
DECLARATION
I hereby certify that the information provided on this application is, to the best of my knowledge, true and complete, and I
authorize the release of the information contained herein to the appropriate Selection Committee.
Some scholarships are funded by private donors who wish to receive limited information about the
recipient(s). This could be general, biographical and/or academic in nature.
Do you agree to the release of such information?
 Yes
 No
Students who indicate “No” will be considered for scholarships and awards that do not have this as a criterion.
I understand that if I receive a scholarship the information I have provided may be subject to verification, and I have read and followed the
instructions for submitting documentation.
Student Signature
Date (dd/mm/yy)
The Michener Institute is committed to protecting personal data. The data collected from this form is for the specific purpose of awarding a scholarship and will
be treated confidentially.
Award winners will be required to provide their Social Insurance Number.
FOR OFFICE USE ONLY:  B  FNAF
SCHOLARSHIP
APPLICATION FORM
PAGE 2
PLEASE PRINT CLEARLY.
APPLICATION INFORMATION
Are you applying for scholarships requiring essays and written statements?
Have you applied for a bursary?
If not applying for a bursary, are you applying for a scholarship based on financial need?
 Yes
 Yes*
 Yes
 No
 No
 No
If yes, please complete and attach Financial Need form.**
* Only one bursary application is needed if applying to more than one bursary or award that requires a bursary application.
**If applying for school award that requires Financial Need Assessment Form, but have submitted a bursary, the Financial Need Assessment
Form is not required. If applying to multiple scholarships and awards that require Financial Need Assessment Form, only one completed form
is required.
Regarding eligibility by year. Year-contingent scholarships, awards, bursaries or grants are determined by semesters completed as of July
30th.

Completed 2 semesters = Year 1

Completed 4 semesters = Year 2

Completed 7 semesters = Year 3

Eligible to graduate June of current year = Graduating Year
SCHOLARSHIP SELECTION
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Dr. Diana Michener Schatz Scholarship (All,
Graduating Year)
Dr. Renate Krakauer Research Scholarship (All, Year
2+)
Entrance Scholarship (All, Entry)
Michener Alumni Association Scholarship (All, Alumni)
BLJC Radiation Therapy Scholarship (Radiation
Therapy, Year 2)
Covidien Scholarship (MRI, Graduating Year)
College of Chiropodists of Ontario Scholarship in
Memory of David Weston, DPM (Chiropody, Year 3)
Kay Boyington Medical Laboratory Science
Scholarship (Medical Laboratory Sciences, Year 2)
LifeLabs Medical Laboratory Science Scholarship
(Medical Laboratory Sciences, Any Year)
True North Imaging Scholarship in Ultrasound
(Ultrasound, Graduating Year)
Alexandra Mitchell Prudencio Memorial Scholarship
(Nuclear Medicine, Year 3)
Please indicate all scholarships being applied for.
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AWARDS SELECTION
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Alpha Charitable Foundations Award (All, Any Year)
Clinical Placement Relocation Award (All, Clinical
Placement)
The Bronwen Roberts Memorial Award (Respiratory
Therapy, Year 2)
TD Insurance Meloche Monnex Student Award (All,
Year 3)
Please indicate all awards being applied for.
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BURSARY SELECTION
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Student Professional Development Grant (All, Any
Year)
Saul Ellis Memorial Bursary (Plan Electric (All, Any
Year)
Dr. Fred Heagy Bursary (Nuclear Medicine, Year 2+)
GRANT SELECTION
Dr. J. E. Prince Nuclear Medicine Scholarship (Nuclear
Medicine, Year 3)
Edward Mallinckrodt Award of Excellence in Nuclear Medicine
(Nuclear Medicine, Year 2)
International Student Award of Excellence (All, Year 2)
Covidien Scholarship (Radiological Technology, Year 3)
Dr. Dan Wilmot Imaging Scholarship (Radiological
Technology, Year 3)
Covidien Scholarship (Respiratory Therapy, Year 3)
Dr. Dan Wilmot Imaging Scholarship (Nuclear Medicine, Year
3)
ProResp Respiratory Therapy Graduating Student
Scholarship of Excellence (Respiratory Therapy, Year 3)
VitalAire Respiratory Therapy Graduate Scholarship
(Respiratory Therapy, Year 3)
Dr. Dan Wilmot Imaging Scholarship (Ultrasound, Graduating
Year)
Ontario Home Respiratory Services Association Respiratory
Therapy Graduating Student Scholarship of Excellence
(Respiratory Therapy, Year 3)
Michener Student Council Awards (All, Year 2+)
Gamma-Dynacare Medical Laboratory Science Award
(Medical Laboratory Sciences, Year 2)
Dr. Allen Gardner Memorial Award (Genetics Technology, Any
Year)
Respan Respiratory Therapy Award for Student Excellence
(Respiratory Therapy, Year 1)
Please indicate all bursaries being applied for.


Tim Colfe & Cecelia Alfonso Radiation Therapy Program
Bursary (Radiation Therapy, Any Year)
OOLab Bursary in Chiropody (Chiropody, Any Year)
FMC Law Humanitarian Field Experience Scholarship (All, Any
Year)
Please indicate all grants being applied for.

FMC Law Humanitarian Field Experience Scholarship
(All, Any Year)

Student Professional Development Grant
SCHOLARSHIP
APPLICATION FORM
PLEASE PRINT CLEARLY.
PAGE 3
If your application requires supporting documentation, please complete this section.
APPLICATION DOCUMENT SUMMARY
Please account for all attached and pending documents as they pertain to the scholarship, bursary, or award to
which you have applied in the space below.
Instructions:
Essays: Applicants must use the essay template and submit a separate essay for each scholarship or award applied
for, as required.
Letters of Reference: Please provide your referee with a copy of the reference template to support your application.
Templates can be found on the scholarship webpage.
Print as many copies of this page as needed.
ESSAYS
#
1
Scholarship or Award Name
Required Documents
 Essay
 Letter of reference from:
1.
2.
3.
 Other (please describe):
A: Attached / P: Pending (Circle One)
A/P
A/P
A/P
A/P
2
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

Essay
Letter of reference from:
1.
2.
3.
Other (please describe):
A/P
A/P
A/P
A/P
3



Essay
Letter of reference from:
1.
2.
3.
Other (please describe):
A/P
A/P
A/P
A/P
4
.



Essay
Letter of reference from:
1.
2.
3.
Other (please describe):
A/P
A/P
A/P
A/P