SWMC Scholarship Application

BEFORE filling out this application, be sure to read the scholarship information to make sure you qualify for a scholarship.
The application and all references HAVE TO BE submitted and received at least 90 days in advance of the beginning of the trip.

PERSONAL INFORMATION

Your First Name(*)
Please let us know your name.

Your Last Name(*)
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Your Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Home Phone
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Cell Phone(*)
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Your Email(*)
Please let us know your email address.

Date of Birth(*)
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Gender(*)
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Name of Spouse
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Names of Children
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COLLEGE INFORMATION

College
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Degree
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Dates Attended
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City and State
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MEDICAL SCHOOL INFORMATION

Medical School
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Degree
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Dates Attended
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City and State
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RESIDENCY INFORMATION

Residency
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Degree
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Dates Attended
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City and State
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Type of Training
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TRAINING

Location
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Degree
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Dates Attended
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City and State
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Type of Training
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PASTORAL INFORMATION

Name and address of your church and pastor
Please let us know your message.

SPIRITUAL INFORMATION

Please tell us about your relationship with God
Please let us know your message.

PROPOSED MEDICAL MISSIONS WORK

Name of Hospital or Location
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Address
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Name of affiliated church or missions organization
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Intended dates of service
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Identify the goals of your proposed mission trip
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Identify the specific expenses for your proposed mission trip
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REFERENCES

Please list the names and titles of three references who will send letters of recommendation. One letter should be from your pastor or a similar person who can address your spiritual interests. The other two should be from people who can address your academic or clinical qualifications. Your references should mail or fax these letters directly to Southwestern Medical Clinic.
Name and Title of Reference 1
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Name and Title of Reference 2
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Name and Title of Reference 3
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APPLICATION DEADLINE

My Mission Trip will take place between
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CERTIFICATION

I certify that the information in and attached to this application is accurate to the best of my knowledge and agree to the terms and conditions of the scholarship as described in the application.
Signed (Type Name)
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Date
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