2024 BEST Summer Medical Academy Scholarship Application Form

The information in this questionnaire is used for grant and reporting purposes only. If approved for scholarship, documentation of income may be requested. Copies of support documentation such as a check stub along with proof of residency may be required.

Student Information

First Name *

Last Name *

Parent/Guardian Information

First Name *

Last Name *

Phone

Current Zip Code

Email Address

My family's combine income(including any child support) in 2020 was *

Less than $30,000

Between $30,000-$50,000

Between $50,000-$100,000

More than $100,000 More than $100,000

Household size:How many dependent children are there in your family *

Is your family receiving any type of public assistance? *

Yes

No

Is there any family members in the US Armed Forces?? *

Yes

No

Household Type(circle the best description of your household) *

Single Parent, female head of household

Single Parent male head of household

Two Parent Household

Parent/Guardian of Child

Please explain all other financial factors contributing to your request for a scholarship *

Please sign certifying that the above information is true and correct to the best of my ability. *

clear

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