DR. ROBERT ADAMS MEMORIAL SCHOLARSHIP
Instruction Sheet
Dear Scholarship Applicant:
The Board of Directors of the McCloud Healthcare Clinic and Dunsmuir Community Health Center is pleased to offer a $1,000
scholarship for the upcoming academic year to honor the memory of its founding physician, Dr. Robert Adams. Application instructions
are found below.
Please note that the application materials differ for current high school seniors and high school graduates.
For current high school seniors: If you are graduating from high school in 2015, please submit:
1. The completed and signed Scholarship Application Form;
2. A typed essay of 500 words or less, not to exceed one page in length describing why you wish to pursue an education in a
healthcare field, what your career plans are after completing college, and any other pertinent information;
3. A list by year of high school offices held, school club activities, community activities, and honors and awards received;
4. An official unopened copy of your most current high school transcript;
5. And a letter of recommendation from a high school faculty member.
For high school graduates (note there are three categories below):
A. If you are currently enrolled in a college, please submit:
1. The completed and signed Scholarship Application Form;
2. A typed essay of 500 words or less describing why you wish to pursue an education in a healthcare field, what your career
plans are after completing school, and any other pertinent information;
3. An official unopened copy of your most current college transcript. (If you have not completed a semester or quarter of
study by the time you apply for this scholarship, please submit an official unopened copy of your high school transcript.);
4. And a letter of recommendation from a faculty member at your college.
B. If you are not currently enrolled in college, but have completed one or more quarters or semesters of college, please submit:
1. The completed and signed Scholarship Application Form;
2. A typed essay of 500 words or less describing why you wish to pursue an education in a healthcare field, what your career
plans are after completing school, and any other pertinent information;
3. An official unopened copy of your college transcript;
4. And a letter of reference from your current employer. If unemployed, a letter from a former employer or colleague can be
submitted.
C. If you have not completed one or more quarters or semesters of college, please submit:
1. The completed and signed Scholarship Application Form;
2. A typed essay of 500 words or less describing why you wish to pursue an education in healthcare field, what your career
plans are after completing school, and any other pertinent information;
3. An official unopened copy of your high school transcript;
4. And a letter of reference from your current employer. If unemployed, a letter from a former employer or colleague can be
submitted.
All required materials must be postmarked no later than April 30, 2015 and mailed to:
McCloud Healthcare Clinic, Inc.
c/o Jennifer Malone, CEO
116 W. Minnesota Ave.
P.O. Box 1143
McCloud, CA 96057-1143
Sincerely,
The Board of Directors
McCloud Healthcare Clinic, Inc.
Dunsmuir Community Health Center
DR. ROBERT ADAMS MEMORIAL SCHOLARSHIP
APPLICATION
Please type or print in ink:
PERSONAL INFORMATION:
1. APPLICANT NAME: _______________________________________________________________
First
Middle Initial
Last
2. PERMANENT ADDRESS (This is the address for mail to reach you throughout the summer and school year.):
____________________________________________________________________
_________________________________________________________
_________________________________________________________
3. HOME PHONE NUMBER: _______________________________________
4. CELL PHONE NUMBER: ________________________________________
5. PARENT OR GUARDIAN (if under 18 years of age): __________________________________
6. DATE OF BIRTH:
________ / _________ / _________
(Month)
(Day)
(Year)
Explain any special conditions or circumstances that might prevent you from continuing your education on
schedule, and/or explain any special circumstances that the Scholarship Committee should take into consideration
when reviewing your application:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
For Graduating High School Seniors:
Name of high school currently attending: ___________________________ Graduation Date: ________
Current GPA: ____________________
College/educational program you plan to enroll in: __________________________________________
When do you plan to start classes: ___________________
Area of healthcare you want to pursue: ____________________________________________________
Degree or certificate desired: ____________________________________
For High School Graduates:
Name of high school you graduated from: ____________________________
Graduation Date: ________
A. Complete the following if you are currently enrolled in a college or an educational program:
Name of college or school you currently attend: ______________________________________
Current grade point average: _____________________
Degree or certificate desired: ____________________________________________
B. Complete the following if you are not currently enrolled in a college or an educational program:
Name of college or school you plan to attend: ________________________________________
When do you plan to start classes: ____________________________
Area of healthcare you want to pursue: _______________________________________________
Degree or certificate desired: ____________________________________________
__________________________________________________________________
___________________________
Signature of Applicant
Date
________________________________________________________
Signature of Parent/Guardian (Required if applicant is under 18 years of age)
_______________________
Date