2023 180 Medical Caregiver Scholarship Application

Full Legal Name*
First Middle Last
Gender*
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Home Phone
Cell Phone
Email*

We will only use your phone or email contact information in the event that we need more information to complete your application or to reach out if you are selected as a recipient.

High School*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- SAT or ACT Score
- High School Cumulative GPA
Current College (if applicable)
Address
Street Address Address Line 2 City State ZIP Code
- College Cumulative GPA (if applicable)
- College Student ID
College you will attend Fall 2022*
Address
Street Address Address Line 2 City State ZIP Code
Major*

How did you hear about this scholarship opportunity?
- Internet Search
- Scholarship Directory
- Facebook
- Friend

Please respond to the following questions
1. List your extracurricular activities (sports, community, employment, etc.) from the last two years. Indicate the dates you participated in the activities.*
2. List any significant awards or honors you have received during the last two years for academic or extracurricular achievements.*
Essay or Video*
Max. file size: 100 MB.
(750 word or 5 minute maximum) Tell your caregiving story. Include who you are caring for (family member or another close loved one), an explanation of your responsibilities as primary unpaid caregiver, and how the role as a caregiver has impacted your life so far as well as your future career goals.
Transcript*
Max. file size: 100 MB.
Please submit an official transcript including your most current semester with your application materials.
College Acceptance Letter*
Max. file size: 100 MB.
Submit a copy of an acceptance letter or current enrollment documentation.
NOTE: uploading files may take a few minutes. Once you click "next", do not refresh or click again. The next page will load as soon as your upload is complete.

Acknowledgement*
In submitting this application, I believe all of the above information to be true and complete and I hereby apply for the 180 Medical Scholarship. I certify that I am not currently receiving full funding for my education. I authorize 180 Medical to obtain and review my academic records. By submitting this application, I authorize 180 Medical to use my name, photo, and any part of essay or video if I am selected as a 180 Medical Scholarship recipient.
Signature*

Please respond to the following questions