Scholarship Application | Oklahoma County Medical Society

Name*

First Middle Last

Email*

Current Address*

Street Address Address Line 2 City State ZIP Code

Permanent Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Date of Birth*

Name of High School, City, State, Graduation Year*

Name of Undergrad School, Graduation Year and GPA*

Over the course of your life, about how many years have you lived in Oklahoma County?*

What is your anticipated income for the current academic year?*

What are your anticipated expenses for the current academic year?*

Marital Status*

Spouse/Domestic Partner Name, Occupation & Employer, if applicable

Do you have children who are currently in your primary, secondary or joint custody?*

Number of Children*

This section will help the selection committee understand your financial needs. "Parent" is defined as the person(s) who primarily supported you during your childhood.

Are your parents . . . ?*

Is your education wholly or partially funded by your parent(s)?*

Wholly
Partially
No financial assistance from parents

How many siblings are in college or will be in college by the end of 2025?*

Parent 1 Information, mark as N/A if no parent

First Last

Parent 1 Address, leave blank if no parent

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Occupation and Employer, if applicable

Parent 2 Information, mark as N/A if no parent

First Last

Parent 2 Address, leave blank if no parent

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 2 Occupation and Employer, if applicable

If none of the parental marital statuses above apply, please explain, (e.g. emancipation dates or spent most of childhood in foster care, etc.

At the end of your second year of medical school, what was your quartile ranking?*

Current Specialty (or undecided)*

In 400 words or less, please tell us about yourself, your educational plans, your long-range career plans, your interest in medicine, your financial need, and/or any other information that you may find valuable.*

Acknowledgement*

The information on this form is true and correct to the best of my knowledge.