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Harwell & Cook Orthodontics
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Why Us
Why Us
Meet the Doctors
Meet Our Team
Invisalign
Invisalign
How Invisalign Works
Invisalign for Teens
Invisalign For Adults
Invisalign Patient Testimonials
Braces
Braces
Braces For Teens
Braces For Adults
Different Types of Braces
Bite Correction
New Patients
Blog
Contact
Scholarship Application
NAME
*
ADDRESS
*
ZIP
Phone
*
Email
*
AGE
DATE OF BIRTH
SS#
US CITIZEN
YES
NO
Middle School Attended
Elementary School
RANK IN CLASS
Numeric Avg.
ACT Composite
SAT Combined
Parent/Guardian Name/Occupations/Places of Employment
Number of brothers/sisters
Ages
How many family members, including yourself, will be in college next year?
List most notable community activities & school-related extra-curricular activities during grades 9 – 12 and check the appropriate grade level(s)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
List special recognition, awards and honors received during grades 9 – 12 and check the appropriate grade level(s).
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
List and describe any work experience during grades 9 – 12 and check the appropriate grade level(s).
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
What college do you plan to attend?
Estimate college expenses for freshman year
Student Photo
Print Name
Student’s Signature
Date
Parent’s Signature
Date
Print Name
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