Instructions:
1. Fill out PART ONE of this application (above) a. Be sure to have your program director sign (above) to validate that you are enrolled in the program and are in good academic standing. b. Please type all your information (aside from signature).

2. PART TWO:
a. Write an essay that is 500-750 words long.
b. Do not write your name on the essay or the name of your school.
c. Do not identify any faculty or staff by name within your essay.

3. PART THREE:
List activities as an ADHA student member and explain how they will help the student become a better professional dental hygienist. Do not write your name or the name of your program in this part of the scholarship application.
PART ONE
DH Student Name:
First Last
ADHA Student membership #:
Mailing address:
Street Address City State / Province / Region ZIP / Postal Code
Phone
School / Program:
Which degree are you working on?
Which other degree?
Expected date of graduation:
Date Format: MM slash DD slash YYYY
Program director signature:
(validating that student is enrolled and in good academic standing)
Today’s date
Date Format: MM slash DD slash YYYY
PART TWO
In what ways has your participation in ADHA student membership impacted your professional development?*
PART TREE

List activities

Explain how they will help the student become a better professional dental hygienist
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Comments
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Application for WI-DHA Student Scholarship

WI-DHA Board of Directors Meeting