SDS Application Page 1

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1 Applications must be received by noon on Monday, June 16, 2014 The Scholarships for Disadvantaged Students (SDS) program promotes diversity among health profession students and practitioners by providing scholarships to full-time students with financial need from disadvantaged backgrounds, enrolled in health professions. All requirements including application information and supporting documentation as well as limitations to the Scholarships for Disadvantaged Students program are set forth by the Health Resources and Services Administration (HRSA) and as such are not amendable by Spalding University. To be eligible to receive funding for the Academic Year, students must be classified as graduate students in their major (MSOT, MSW, PsyD) students must be full-time for their major as defined by the University Catalog students must have submitted a FAFSA for the academic year students must demonstrate financial need as a result of a disadvantaged background students must be willing to complete program fieldwork/practicum requirements in medically underserved communities (MUC) students must be committed to post-degree career paths working with underserved populations in primary care settings. HRSA defines independent as being at least 24 years old and not having been listed as a dependent on parents income tax for 3 or more years. If a student is at least 24 years old and cannot prove independent status, then he or she would be considered dependent and the parental income will be used to determine economic disadvantage. To apply for the Scholarships for Disadvantaged Students program, ALL students must submit the following items. Please DO NOT STAPLE. Students are responsible for making copies of all documents to be submitted; the SDS Program Office will not make copies of documentation. Completed Application. Copy of drivers license, birth certificate, or passport for proof of age Copy of IRS federal 1040 tax forms for 2011, 2012, and o ONLY the form marked 1040 in the bottom right corner (1040A, 1040 EZ ) need be submitted. All addendums, worksheets, and schedules should be excluded. o If you are independent of your parents, please submit YOUR tax documents. If you are considered dependent, please submit YOUR PARENTS tax documents. o FAFSA documents may NOT be submitted in place of IRS documents. Incomplete applications will result in the application not being considered for funding. The primary indicator of disadvantaged for the Scholarships for Disadvantaged Students program at Spalding University is economic and, therefore, preference will be given to those students who meet that criterion first. Please note that racial or ethnic minority status by itself does not qualify as disadvantaged. Applications must be received by noon on Monday, June 16, 2014 Students may deliver applications to ELC 200, applications to or mail applications to Judy Luther, SDS Coordinator, Spalding University, 845 S 3 rd Street, Louisville, KY Incomplete packets will not be accepted. Please DO NOT STAPLE. Students are responsible for making copies of all documents to be submitted; the SDS Program Office will not make copies of documentation. Students will be notified by mail of award or rejection of application. Once awards have been made, no appeals will be considered for further funding SDS Application Page 1

2 I am currently a full-time graduate student enrolled in the degree program selected below. I will be a full-time graduate student in the degree program selected below. Master of Science, Occupational Therapy Master of Social Work Psychology (PsyD) I submitted a Free Application for Federal Student Aid (FAFSA) for academic year Yes No (If no, applicant is not eligible.) I agree to complete program fieldwork/practicum requirements in medically underserved communities (MUC), and I am committed to working with underserved populations in primary care settings upon completing my training program. Yes No (If no, applicant is not eligible.) Student Information (please print legibly) Spalding Student ID Number: Name: Last First Middle Name or Initial Mailing Address: Number Street Apt. No. City State Zip code Telephone number: address: Gender: Female Male Birth Date (xx/xx/xxxx) Age as of 6/30/ SDS Application Page 2

3 Ethnicity One of the criteria that will be used to determine scholarship eligibility is membership in one of the traditionally under-represented groups attending higher education institutions and/or within the student s major, as defined by HRSA. Please indicate your ethnic origin/race below: Are you of Hispanic/Latino descent? Yes No Please select one or more of the following: American Indian or Alaska Native A person having origins in any of the original peoples of North/South and/or Central America and who maintains a tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands Thailand, or Vietnam. Black or African American A person having origins in any of the black racial groups of Africa. Native Hawaiian or other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands. White A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Individual Characteristics Please select a response for each of the following: Yes No Are you from a disadvantaged background as defined below? Comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession OR Comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes Yes No 1 st generation college student (neither parent has completed a 4-year degree) Yes No 1 st generation graduate degree-seeking student (neither parent has completed a graduate degree Yes No Are you from a rural residential background? If yes, please indicate county, state, and zip code: Yes No Are you a veteran? If yes, please select status: Active Duty Military Reservist Prior Service Retired SDS Application Page 3

4 Financial Information/Eligibility HRSA defines independent as being at least 24 years old and not having been listed as a dependent on parents income tax for 3 or more years. If a student is at least 24 years old and cannot prove independent status, then he or she would be considered dependent and the parental income will be used to determine economic disadvantage. Please select one of the following and submit appropriate tax forms with application. DO NOT STAPLE. Include ONLY legible 1040 forms. I am 23 years of age or younger, so according to HRSA I am considered a dependent of my parents. Thus, I am submitting copies of my parents 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums). I am 24, 25, or 26 years of age, but I have been listed as a dependent on my parents tax returns during the last 3 years. Thus, I am considered a dependent of my parents as defined by HRSA and I am submitting copies of my parents 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums). I am at least 24 years old and considered an independent student because I have NOT been claimed as a dependent for at least 3 years. Thus, I am submitting copies of my 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums). I am at least 24 years old and considered an independent student because I have NOT been claimed as a dependent for at least 3 years. I did not file income tax returns for one or more of 2011, 2012, 2013, so I am submitting verification from the IRS stating such. I understand that it is my responsibility to visit the IRS office in person to obtain the necessary forms stating I did not file. As reported on parents or student s 2013 Federal 1040 tax form: Number of Number of $ (AGI) Exemptions Dependents Adjusted Gross Income The table below lists the income levels that meet the 2012 economic disadvantage criterion. Please place an X next to your eligibility level to match # of exemptions. Size of Parents or Student s family * Income Level ** 1 $22,980 2 $31,020 3 $39,060 4 $47,100 5 $55,140 6 $63,180 7 $71,220 8 $79,260 * Includes only dependents listed on Federal Income tax forms. **Adjusted gross income for calendar year SDS Application Page 4

5 Summary of Eligibility Because the need of the eligible Spalding students is greater than the maximum amount of available SDS funds, each program will rank students based on Financial Information/Eligibility Amount of unmet need as the Primary Indicator. All criteria in the application will be reviewed with consideration also given to under-represented minority status, 1 st generation college student, and 1 st generation graduate degree-seeking student. Post-Degree Career Path (please select all that apply) After graduation, I intend to practice in a primary care setting. After graduation, I intend to practice in a medically underserved area. After graduation, I intend to practice in a rural setting (areas outside of cities and towns). By signing this statement, I agree to the following: To the best of my knowledge, the information I have provided in this application is true and accurate. If asked, I will provide proof of accuracy of any response I have made on this application. I understand my full application is to be reviewed by administrative and council members of the Scholarships for Disadvantaged Students in the Health Professions grant program. I understand that to be eligible I must be enrolled full-time as a graduate student in my degree program (MSOT, MSW, PsyD) as defined by the University Catalog. I must have submitted a FAFSA for academic year I agree to complete program fieldwork/practicum requirements in medically underserved communities. If I receive a scholarship, I understand I must maintain full-time enrollment as defined by the University Catalog during the academic year. To retain this scholarship, I must maintain good standing according to the policies of my degree program as defined in the University Catalog. If I receive a scholarship, I agree to respond to surveys requesting additional information to fulfill HRSA reporting requirements. If I fail to abide by all parts of this statement, I will relinquish this scholarship immediately. Signature of Applicant Date Please Print (or type) Name of Applicant SDS Application Page 5

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