2026 Scholarship Recommendation Form

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This recommendation form is to be used for the following scholarships:

- BJ Long Memorial Scholarship

- Nicole Eusebio Memorial Scholarship

- Texas Dental Placement Network Scholarship

- TDHA Scholarship

- Cloud Dentistry Scholarship

- Dental Hygiene Basics Scholarship

- Nancy Tibbits Scholarship

Applicant Instructions:

Submission of this recommendation form should be completed by a faculty member, SCADHA advisor, or local/state component member most familiar with you. Along with this recommendation form, supply the person completing the recommendation with your statement on your long-term career goals after graduation and your intended contribution to the dental hygiene profession. This form is due on December 19, 2025 11:59pm CST. There will be no exceptions. Applications are not considered complete without this recommendation form.

Instructions in completing this form:

A student from has applied for a 2025 Scholarship. Your evaluation of the applicant is requested for use in the selection of scholarship recipients. This recommendation form must be submitted on or before December 19, 2025 at 11:59pm CST for the student to be considered. The applicant should have provided you with their statement about their long-term goals after graduation and intended contribution to the dental hygiene profession. These statements are a part of the student’s section of the application. This may help you better comment on how the applicant’s qualifications related to their stated goals. All recommendations received will be verified. If you have any questions, please contact the Scholarship Chair, Angela Do, at tdhascholarship@gmail.com.

Your Name: *

Email Address: *

Phone Number: *

ADHA Member # (Enter N/A if not a member): *

Student Name (first and last): *

School Name of the Student: *

Relationship to the Student: *

Part I:

Please rate your level of agreement with the following statements regarding the statements in which you should have received from the applicant:

0 - The applicant’s statement did not address this; 1 - Strongly Disagree; 2 - Disagree; 3 - Neutral; 4 - Agree; 5 - Strongly Agree

1. The applicant's qualifications and student performance has prepared them to achieve their long-term career goals. *

2. The applicant’s qualifications and student performance has prepared them to achieve their intended contribution to the dental hygiene profession. *

Part II:

Please answer the following questions to the best of your knowledge.

1. What SCADHA activities has this student been involved in or led? *

2. How does this student display attributes of a professional capable of entering the dental hygiene profession in relation to their leadership qualifications, teamwork skills, promotion of a prevention culture, and clinical excellence? *

3. Has there been any occurrences which the student has gone above-and-beyond expectations which sets them apart to be chosen as a scholarship recipient? *

I recognize that the purpose of this document is to provide a fair representative student analysis. The responses indicated constitute my professional/educational opinion of the student. I hereby authorize investigation and verification of all statements contained within this application. I understand misrepresentation or omission of facts is cause for disqualification of the applicant. *

Yes

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