Student Application Form

Albert E. Carlotti Dental Hygiene Scholarship

Instructions: Please print clearly or type. Return completed form to:

CCRI Foundation's Albert E. Carlotti Dental Hygiene Scholarship Committee
c/o Director of Dental Hygiene
Community College of Rhode Island
1762 Louisquisset Pike
Lincoln, RI 02865-4585

SCHOLARSHIP NOT AVAILABLE SPRING 2009

Name_________________________________________ Student I.D. #________________________

Address__________________________________ City________________ State______ Zip________

Telephone____________________________________ email_________________________________

1. Will you be graduating from the Dental Hygiene Program? Yes__ No__

2. Are you a member of the Student Dental Hygiene Association? Yes__ No__

3. List any offices held:

4. List any honors and/or awards you have received.

5. List any elected offices held in student clubs, including the name of each organization, the title of the
office held, and the years in office.

6. Please describe an example of a leadership role that you exhibited since you have been at CCRI.
(Attach additional pages as necessary.)

7. Why have you chosen to study Dental Hygiene? (Attach additional pages as necessary.)

8. Have you applied for other CCRI scholarships, funds or awards? Yes___ No___

If yes, please list:

I grant my permission to the Scholarship Review Committee to review my academic standing with CCRI’s Office of Admissions and Records, to review my financial need with CCRI’s Financial Aid Office, and to use my name and photo for publicity purposes.

__________________________________
Student Signature/Date

Important Note: Scholarship recipient is required to write a thank you note (memo and sample thank you note) to the scholarship donor, and provide a brief biography (printable bio form) about themselves and their education/career goals and return both to: Geraldine Peixoto, CCRI Foundation, Flanagan Campus, 1762 Louisquisset Pike, Lincoln, RI 02865.Please contact the CCRI Foundation if you need assistance in completing this responsibility at 333-7150 or e-mail at foundation@ccri.edu.