Michigan PA Foundation
Annual Scholarship Award.
4.2, May 13, 2013
Must be a physician
assistant student in their final clinical year currently enrolled in a
PA Program in Michigan as of August 1, 2013.
Must exhibit one or more of the following:
1. Financial Need,
2. Outstanding scholarship,
2. Professional involvement, and/or
3. Community service,
Financial need means that which may impact on the student's ability to
concentrate on academic requirements for successful completion of physician
assistant training. Professional involvement / Community Service can be
whaterver you believe to pertain: Prior or current research, independent
and organizational initiated volunteer activities and programs.
Applications must be received by August 1, 2013, which includes the verification
of a physician assistant senior student status by the PA program director.
There are two methods
available to complete this Application.
The first is to complete the form, print this page, and mail it by the
USPS to Jack Kircher, as given below. Your Program Director (or their
representative) must complete the Program Director Verification
of Student Status section at the end of this form and mail or
email to Jack at:
Jack Kircher, PA-C
Scholarship Committee Chair
905 Cecelia Court
Essexville, MI 48732-2102
2. The second method
available to submit this form again requires your completion of each section
in the form. Then copy the form and paste into an e-mail to Mr. Kircher
at email@example.com. You will
then need to ask your Program Director to complete the Program Director
Verification of Student Status section below, copy and paste in
an e-mail to Jack or print the
Program Director section and mail it to Jack as given above.
recipients will be contacted by September 20, 2013. Formal Award presentation
will be made at the Annual Fall Michigan Academy of Physician Assistants
CME Conference, Friday, October 11, 2013. The 2013 MAPA Conference is
at the Grand Traverse Resort in Traverse City. The presence of the award
recipients at the Award Ceremony and permission for photographs is requested.
Our Promise to you.
We consider the information
on the Scholarship Application you provide to be privileged and confidential.
Only the Scholarship Application Review Committee will see your information.
Particulars will not be shared with other Foundation Board of Directors
members or outside parties. It will never be sold, bartered or released
to any third parties, including your classmates or PA Program Personnel.
Should we determine
that you provided false information on your application, the Foundation
will request the Award be returned to us. We will pursue legal avenues
should difficulties arise.
The Foundation reserves
the right to use your name as a recipient of the Scholarship Award during
the Award Presentation, in promotional materials, and to media outlets.
Should you be selected to receive an Award, we will ask you to provide
a short comment on how the Award was helpful to you in continuing or completing
your PA education. We reserve the right to also use these comments in
promotional material in fund raising activities.