Davlin Family Scholarship in Aging Application

Deadline: Please submit your completed application no later than November 10

Student Information

First Name

Preferred Name

Last Name

Dominican Student ID#

Cell Phone Number

Email Address

Date of Birth is collected to prevent the creation of duplicate records.
Date of Birth

Mailing Address

Country

Street

City

Region

Postal Code

Academic Information

What is your current student status?

Advanced Standing Program

Full Program

What is your course load?

Full Time

Part Time

Current GPA

Have you received the Kott Scholars Program this year?

Yes

No

Agency Information

What is the name of your current internship agency?

What is the name of your agency practicum instructor?

Documentation

Personal Statement

Please briefly address the following questions (approximately 500 words).

1. Describe examples of your commitment to providing social work services to our aging population and their families. Where do you see yourself 5 years from now?

2. What would you like to gain from an internship with older adults?

3. Discuss how inter-generational programs or activities impact your current internship placement. How might you propose increased inter-generational interaction at your placement?

Statement is required for scholarship application submission

I give Dominican University permission to use my name and photo for marketing purposes pertaining to this scholarship.

Yes

No

Signature

By typing your name in the signature field above, you are certifying your application with an electronic signature. I certify that all the information in my application is accurate and true.