MOLA Scholarship Application 2019
Please complete the following application to be considered for MOLA's scholarship program. Deadline is December 13, 2019 and also includes post-mark or electronic receipt of the supporting documentation. For full application instructions, please review the scholarship website at www.chicagomola.com
Email address *
Section 1: Demographics
First name: *
Your answer
Middle name (leave blank if N/A)
Your answer
Last name: *
Your answer
Date of Birth (month/day/year) *
MM
/
DD
/
YYYY
Phone number. (Please confirm that you have entered the 10 digit number accurately including area code XXX-XXX-XXXX.) *
Your answer
Local address: *
Your answer
Unit/floor/apartment/suite:
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Permanent address: *
Your answer
Unit/Floor/Apartment/Suite:
Your answer
City: *
Your answer
State: *
Your answer
Zip code: *
Your answer
Racial/Ethnic self-identification (please select any and all that apply). Are you of Hispanic, Latino, or Spanish origin? *
Required
What is your race? *
Required
Optional: You may describe your self-identified race/ethnicity if not otherwise specified above.
Your answer
Section 2: Education
What is the highest degree that you have been awarded? (e.g., high school diploma, BA, BS, MA, MPH, MD, PhD, etc.) *
Your answer
Current Institution name: *
Your answer
What degree are you currently seeking? (e.g., BA, BS, MA, MPH, MD, PhD, etc) *
Your answer
Current Institution address: *
Your answer
Current Institution City: *
Your answer
Current Institution State: *
Your answer
Current Institution Zip code: *
Your answer
Current Major/concentration: *
Your answer
If you attended any prior institutions at college level or above, please enter for each one: Name of institution, City, State/Province/Country, your major/concentration, and degree obtained upon graduation. If you did not graduate, please explain. If you have not attended any prior institutions at college level or above, please respond N/A. (If you need more space, please submit it with the supplemental documentation in section 4.) *
Your answer
Have you faced any disciplinary actions during your time enrolled at any academic institution due to legal, academic, or code of conduct violations? *
If you answered “yes”, please explain (If additional space is needed, you may submit it with the supplemental documentation in section 4):
Your answer
Section 3: Scholarship and Academic/Professional Development:
The MOLA Scholarship program aims to provide under-represented students of Hispanic/Latino heritage with an interest in pursuing a career in healthcare or medicine with a monetary award to utilize towards the cost of their education (tuition, housing, academic fees, textbooks, personal computer/laptop, etc). Scholarship recipients must commit to completing a scholarly project in the next academic year that includes a minimum of 5 hours/week over a 6 month period, and also commit to present the results of this project at the 2019 MOLA Latino Health Symposium. In order to provide the scholarship committee with the most complete information possible, please provide your answers to the following questions:
1) In what area in healthcare do you intend to practice? Please specify field of practice, as well as any possible sub-focus/discipline within that field that you may aspire to (if applicable) Please limit your response to 150 words: *
Your answer
2) How do your professional and/or academic goals align with the stated objectives of the Chicago MOLA Scholarship program? Please limit your response to 300 words: *
Your answer
3) What research topic/area of interest do you intend to pursue as an honoree of the MOLA scholarship program? Please limit your response to 150 words: *
Your answer
4) Please describe how your Hispanic/Latino heritage may have an impact in your future healthcare career. Please limit your response to 150 words. *
Your answer
Section 4: Agreements & Supporting Documentation
The following materials should be submitted according to the instructions on the MOLA Scholarship website, via email attachment to Contact@chicagomola.com. Please include “YOUR NAME - MOLA SCHOLARSHIP SUPPORTING DOCUMENTATION” in the subject line of your message. If electronic submission is not possible, materials can be mailed to the following address (MOLA, Attn: Scholarship Subcommittee, P.O. Box 577672, Chicago, IL 60657-3012) and must be postmarked by the deadline below. Please note that applications will not be considered "complete" until all materials have been received.
1) 2 letters of recommendation.
2) Documentation in support of your stated financial need. Please include a FAFSA form. Additional documents may also include income tax statements or other documentation demonstrating financial need.
3) Letter of good standing from your current educational institution or other documented proof of good standing.
4) Most recent academic transcript.
5) Up-to-date Curriculum Vitae.
I acknowledge that I have read the above supporting documentation requirements and instructions for submission. *
If selected as a MOLA Scholar, I agree to complete a scholarly project that includes a minimum of 5 hours/week over 6-month period per schedule arranged by individual awardees between March and October, 2020. Awardees will be assigned a MOLA physician or health professional mentor to supervise and guide their work. *
If selected as a MOLA Scholar, I agree to present my project at the MOLA Latino Health Symposium in the Fall of the following calendar year in Chicago (planned for October 2-3, 2020; exact dates to be confirmed). *
A copy of your responses will be emailed to the address you provided.
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