Student Application Form

Underhill Dental Hygiene Book Award

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

CCRI Foundation's Underhill Dental Hygiene Book Award Committee
c/o Director of Dental Hygiene
Community College of Rhode Island
1762 Louisquisset Pike
Lincoln, RI02865-4585

Applications must be hand delivered by 4 p.m. or postmarked no later than April 1.

Name__________________________________________ Student I.D. #__________________________

Address______________________________ City_____________________ State_____ Zip___________

Telephone________________________________ email________________________________________

1. Are you enrolled in the Dental Hygiene Program? Yes__ No__

2. Have you completed at least two semesters of study at CCRI? Yes__ No__

3. Are you currently receiving Financial Aid? Yes__ No__

4. What is your G.P.A.? Why have you chosen to study Dental Hygiene? (Attach additional pages as necessary.)

5. Why should you be selected for the Underhill Dental Hygiene Book Award? (Attach additional pages as necessary.)

6. 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.