Wisconsin Physical Therapy Fund Scholarship Application

Wisconsin Physical Therapy Fund Scholarship ApplicationApplicants must fill out the application below or supply the same information requested in thisapplication in approximately the same format.Do not send your resume as a substitute for the application process.Name:Address: (Indicate address to which you would like scholarship disbursement sent.)Phone 1: Phone 2:Email:Verification of Requirements:APTA/WPTA Member Number:Anticipated date of graduation:(Apply only if you will be in your last year of PT(A) school within the year following receipt of an award.)List post high school education institutions you have attended, starting with your present school:School Degree Received or Anticipated Dates enrolledCurrent Cumulative GPA:Other Post High School Education (please explain – ie. continuing education, certifications, etc.)

List all employment held during the past 4 years:Employer Nature of Work From/To Hours/WeekCurrent monthly household income(include spouse, partner, significant other; exclude parental income):Number of applicant’s dependent children:Ages:Total Current Debt Related to Education:Available Income to Meet Expenses:Personal Funds (savings, etc.)Student Earnings While in SchoolScholarships/GrantsFamily Monetary Support (parental assistance)(for school and living expenses)Other Income (explain)This Year (Actual)Next Year (Estimated)LoansTotal for above 5 items(Total Non-Loan Support)Please add pertinent information or special circumstances that you would like us to consider whenreviewing this application:

The Chris Crivello Scholarship honors a student who demonstratesa commitment to the community and to the practice of physical therapy.Describe your extracurricular and volunteer activities that demonstrate your commitment inthese areas (use space below or separate pages).Do NOT list volunteerism required for entry into your program or required as part of a course.Do NOT list any activities for which you received wages or a stipend.The Tracy Rasor Scholarship honors a student who demonstratesan interest in Sports Medicine Physical Therapy.Describe your academic and extracurricular activities that demonstrate your interest in thisarea (use space below or separate pages).Signature:_______________________________________________________Your applications will not be considered if we have not received all of the information(including the two letters of recommendation) by March 4 th .