Medical H.E.L.P Scholarship Application

To qualify for a Medical HELP Scholarship, applicants must first complete the Medical H.E.L.P. Registration form and communicate with Medical H.E.L.P. staff to confirm attendance.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Which Medical HELP course are you interested in?

4-week Comprehensive session

2-week Intensive session

Other (ex: Custom Program)

Please select all that apply:

I am a U.S. Military Veteran.

My parent(s) or immediate family members are active in the U.S. Military or are U.S. Military Veterans

I am a first-generation college student (my parents did not attend higher education).

I have a diagnosis of an Specific Learning Disability and/or ADHD

If currently employed, please provide name of employer and annual salary:

Indicate why you feel that you need and are qualified to receive a Scholarship for Medical HELP.