Medical Assistant Scholarship Application

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* 1. First name

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* 2. Last name

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* 3. Contact information

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 4. I am an Outagamie County Resident. *This is an Outagamie County grant funded scholarship; all applicants must be a current resident of Outagamie County.

Yes

No

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* 5. Please indicate your race/ethnicity.

American Indian/Alaskan Native

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White

Other

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* 6. If you are in school, what is your current cumulative GPA?