Student Application Form
Dr. Joseph A. Yacovone Scholarship for Dental Assisting Students
Instructions:Please print clearly or type. Return completed form and mail to:Dr. Joseph A. Yacovone Scholarship for Dental Assisting Students
c/o Virginia Cairrao, CDA
8 Colt Avenue
Bristol, RI 02809
Applications must be postmarked by August 14 for fall semester/January 1 for spring semester.
Name_________________________________________ Student I.D. #__________________________
Address_________________________________ City________________ State____ Zip_____________
Telephone__________________________________ email_____________________________________
1. Have you been accepted to CCRI’s Dental Assisting Program for the upcoming (NOTE: select Fall for August application; select Spring for January Application)
Fall Semester? Yes__ No__
Spring Semester? Yes__ No__
2. Have you enrolled in the Dental Assisting Program in the upcoming fall semester? Yes__ No__
3. Describe any personal circumstances related to your financial need for this Scholarship.
(Attach a maximum response of one page.)
4. Why have you chosen to study Dental Assisting? (Attach a maximum response of one page.)
5. What high school did you graduate from? ______________________
When? __________
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.
