1. Healthcare

DEPARTMENT OF
PHYSIOLOGY AND HEALTH SCIENCE
SCHOLARSHIPS AND AWARDS APPLICATION
Instructions:
1. Complete
this application
online
1. Download
the application
to your
computer, fill it out using Adobe Reader, or Acrobat.
2. Print 2.
and
sign
the
Application
and attach
the the
required
documents,
as listed at the end of the
Print
and
sign
the application
and attach
required
documents,
application.
as listed at the end of this application.
3. Submit your completed application and attached documents to:
3. Submit your completed application and attached documents to:
ATTN:
Honors&and
Awards
Selection
Committee
ATTN:Honors
Awards
Selection
Committee
Department
of
Physiology
and
Health
Department of Physiology and HealthScience
Science
Cooper
Cooper Science
Science Building,
Building, CL325
CL 325
Ball State
State University
University
Ball
Muncie,
IN
47306
Muncie,
47306
I. Scholarships/Awards
(Please check all Scholarships/Awards for which you wish to be considered. Only the scholarships that require an application are listed.
I. Scholarships/Awards
The committee cannot consider a student for a scholarship unless the student has applied for that scholarship.)
Check all for which you wish to be considered. Only those which require an application are listed.
Undergraduate Health Science
Undergraduate Health Science
c McKenzie-Walkup Book Scholarship
McKenzie-Walkup Book Scholarship
c McKenzie-Walkup Intern Scholarship
McKenzie-Walkup Intern Scholarship
c Ann B. & David A. Westerlund Scholarship in Honor of James F. McKenzie for Non-Traditional Students
Robert H. and Esther L. Cooper Science Scholarship
Awarded to eligible undergraduates 25 years of age or older. Birthdate:______/_____/________
RussellE.E.Siverly
SiverlyMemorial
MemorialResearch
ResearchAward
Award
c Russell
Sherri H.
Hittson
Memorial
Scholarship
c Robert
and Esther
L. Cooper
Science Scholarship
The
Zeberl
Family
Health
Education
c Sherri Hittson Memorial Scholarship Scholarship
Warren
E. Family
Schaller
Scholarship
c The
Zeberl
Scholarship
c William
Bock
Health Education Scholarship
Graduate
Health
Science
c Charles R. Carroll Health Education Scholarship
Charles R. Carroll Health Education Scholarship
c Warren E. Schaller Scholarship
Elizabeth A. Neilson and George H. Neilson Scholarshop
Undergraduate
Physiology
Robert
H. and Esther L. Cooper Science Scholarship
c Robert
Esther
L. Cooper
ScienceAward
Scholarship
RussellH.E.and
Siverly
Memorial
Research
The Zeberl Family Health Education Scholarship
Graduate Physiology
Warren E.E.Schaller
c Raymond
Henzlik Scholarship
Physiology and Anatomy Research Award
c Robert H. and Esther L. Cooper Science Scholarship
Undergraduate Physiology
Robert H. and Esther L. Cooper Science Scholarship
Russell E. Siverly Memorial Research Award
Graduate Physiology
Raymond E. Henzlik Physiology and Anatomy Research Award
Robert H. and Esther L. Cooper Science Scholarship
Russell E. Siverly Memorial Research Award
Deadline
Deadline
12:00 Noon
Noon
12:00
February
13, 2015
Monday,
January
22
II. Personal Information
E-mail
Name
Last
First
MI
Current Phone
Current Address
Street Address
City
Apt.
State
Zip Code
Permanent Phone
Permanent Address
Street Address
City
Apt.
State
Zip Code
III. Academic Information
Current Major(s)
GPA
Current Minor(s)
GPA
Year in School
Overall GPA
Anticipated date of BSU Graduation
Completed Degree(s)
Major(s)
GPA
Minor(s)
GPA
College/University
Graduation Date
List any academic honors or awards you have received :
Overall GPA
IV. Professional Activities and Involvement
List health science or physiology related extra-curricular activities in which you have participated (volunteer experiences, work in
schools, agencies, honorary societies, etc.).
Name of Organization
Position or Office
Date
List and describe employment, internship, or practicum experience you have had in the health science or physiology area.
Employer/Agency
Dates of Employment
to
Dates of Employment
to
Describe your basic responsibilities and tasks
Employer/Agency
Describe your basic responsibilities and tasks
V. Statement of Professional Contribution
Describe any contributions you have made to promote school, community, public, or environmental health or physiology.
VI. Additional Information
If applying for the Robert H. and Esther L. Cooper Science Scholarship, please make a statement concerning your use of tobacco,
alcohol, and illegal drugs.
List two professional references below, at least one a department faculty member.
Name
Title
Business/Organization
Phone
E-mail
VII. Applicant Statements
Please read the following statement carefully.
If I am selected to receive a scholarship/award*, I understand and give permission for the following: Release of my information
and photograph along with information about the respective scholarship/award by the Department of Physiology and Health
Science and/or Ball State University Marketing and Communications to my hometown newspaper and the department’s Web
site, display board, and alumni newsletter.
Applicant's Signature
Date
*Upon receipt of award/scholarship, student will receive a photo release form and a hometown newspaper informational form to be completed and returned to the
Department of Physiology and Health Science.
Attach the following documents:
1.
2.
Current
Resumé
1. CURRENT
RESUMÉ
Current
DegreeWorks
and transcripts
for all academic work completed after high school.
2 CURRENT
DAPR and/or
TRANSCRIPT
For the Siverly Award a:
SiverlyProposal
and Henzlik awards
For
1.the
Research
1. Research Proposal
For the Ann B. & David A. Westerlund Scholarship in Honor of James F. McKenzie for Non-Traditional Students:
1. Student must have filed a FAFSA with the Scholarship and Financial Aid office in order for
For Schaller award
eligibility to be determined, as the award is based upon financial need.
1. Two letters of support
Submit your completed application and attached documents to:
ATTN:Honors & Awards Selection Committee
Department of Physiology and Health Science
Cooper Science Building, CL 325
Ball State University
Muncie, IN 47306
Deadline
12:00 Noon
Monday, January 22