IBERIA PARISH MEDICAL AUXILIARY

SCHOLARSHIP PROGRAM APPLICATION

C/O Cathy Melancon

P.O. Box 11036

NEW IBERIA, LA 70562-1036

NAME: ____________________________     DOB: ___________   AGE: _____

ADDRESS: _______________________________________________________

TELEPHONE NUMBER: (HOME)_______________  (CELL)______________

EMPLOYER: ________________________  TITLE:_______________________

SPOUSE’S NAME (if applicable): ________________________________

SPOUSE’S EMPLOYER: ______________________________

NUMBER OF DEPENDENTS AND AGES: _____________________________

ARE YOU CURRENTLY ENROLLED IN SCHOOL?   YES    NO

     IF YES, GIVE LOCATION, MAJOR COURSE OF STUDY, AND GPA

          ____________________________________________________________

         _____________________________________________________________

 ARE YOU RECEIVING ANY SCHOLARSHIPS/GRANTS?   YES    NO

     IF YES, PLEASE GIVE DETAILS __________________________________

          ____________________________________________________________

HOW ARE YOU CURRENTLY PAYING FOR YOUR EDUCATION?

     _______________________________________________________________

PERSONAL AND CAREER GOALS:  _________________________________

_________________________________________________________________

BRIEFLY LIST ANY EXTRACURRICULAR ACTIVITIES, COMMUNITY WORK, 

     OR SPECIAL INTERESTS: ____________________________________________

          _________________________________________________________________

          _________________________________________________________________

          _________________________________________________________________

BRIEFLY DESCRIBE WHY YOU FEEL YOU ARE DESERVING OF THIS 

     SCHOLARSHIP:  ____________________________________________________

          _________________________________________________________________

          _________________________________________________________________

          _________________________________________________________________

          _________________________________________________________________

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PLEASE RETURN THE COMPLETED APPLICATION, ALONG WITH A COPY OF YOUR TRANSCRIPT TO THE ADDRESS ABOVE.

SCHOLARSHIP FUNDING AVAILABLE THROUGH PROCEEDS FROM THE IPMA RUN FOR FUNDS AND GENEROUS LOCAL BUSINESS SPONSORSHIP OF THE ANNUAL RUN.