2023 180 Medical Scholarship Application

Full Legal Name*
First Middle Last
Gender*
Home 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.

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 minutes maximum) Tell your story. Include how your medical condition has affected your life and explain your goals for the future.
Transcript*
Max. file size: 100 MB.
Please submit an official transcript including your most current semester with your application materials.
Diagnosis*
Max. file size: 100 MB.
Must submit a physician’s note stating diagnosis.
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