Scholarship Applications – Southwestern Medical Clinic Foundation

Scholarship Application

We appreciate your interest in using your gifts from God to serve communities in need of medical care. Please provide the following information to apply for funding from our organization.

Personal Information

Name(Required)

First Last

Phone(Required)

Home Address(Required)

Address Line 1 Address Line 2 City State Zip Code

Email(Required)

Enter Email Confirm Email

Birthdate(Required)

College - Undergraduate

Name of School(Required)

Degree - Undergraduate(Required)

Dates Attended(Required)

City & State(Required)

City State

Graduation Date(Required)

Medical / PA / NP School

Name of School(Required)

Degree(Required)

Dates Attended(Required)

City & State(Required)

City State

(Expected) Graduation Date(Required)

Residency

Hospital(Required)

Specialty(Required)

Dates Attended(Required)

City & State(Required)

City State

Expected Completion Date(Required)

Short-Term Medical Mission Trip Information

Name of Hospital(Required)

Hospital Location(Required)

City State Country

Trip Dates(Required)

Trip Goals(Required)

Sending Affiliated Church or Mission Organization(Required)

Spiritual Information

Please tell us about your relationship with God(Required)

Medical Mission Trip Costs

Airfare(Required)

Visa(Required)

In Country Costs (Housing, Food, etc.)(Required)

Other Trip Funding Sources Amount(Required)

Amount of Trip Costs Still Needed(Required)

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