Medical & Dental Spanish
Scholarship Application
Instructions:

1) Please complete this form.
2) Also, provide us with the requested information
to certify that you have financial need and are
enrolled. We will obtain these certifications.
3) Electives begin every Monday. Please indicate
the starting and ending dates for your participation.
These dates can be tentative. We will work with
your schedule.
4) Finally, after submitting the form, come back
to this page and click on the payment link at left.
5) Scholarships are granted after the application and
payment are received.
6) Prepare for a great time and a fantastic learning
experience.
Personal Information
First Name:  
Middle Initial:  
Last Name:  
E-Mail Address::  
Address 1:  
Address 2:  
City:  
State:  
Zip Code:  
Telephone:  
School Information
Professional School Name:  
Professional School Type::  
Number of Years Completed:
Elective Information
Starting and Ending Dates:
Length of Elective (weeks):
Financial Need Certification (person we can contact)
Name of Person to Certify:
Title of Person to Certify:
E-Mail Address:
Enrollment Certification (person we can contact)
Name of Person to Certify:
Title of Person to Certify:
E-Mail Address:
Message/
Question:		  

Copyright 2007: Mayan Medical Aid, Inc.