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Steven Charles Barnes 2017-18 Memorial Scholarship ApplicationPersonal InformationName: ________________________________Date of Birth: __________________________Phone: ________________________________Email: _________________________________ Address: ______________________________Academic InformationHigh School:_____________________Name of College: _________________ Activities and InterestsA: List and/or briefly describe your extracurricular activities _____________________________________________________ ______________________________________________________ ________________________________________________________ B: List and briefly describe volunteer activities in which you have been involved ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ C: List honors or awards you have received __________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ D: List and briefly describe work experience ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________Essays A: What are you currently doing to make your community a better place? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________B. How will you use your college education to make your community a better place? ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________Eligibility (Only facilities with full service contracts are available)Affiliation (Circle One):LifeCare Hospital of Dallas LifeCare Hospital of Fort WorthLifeCare Hospital of Plano Kindred Hospital Dallas – CentralKindred Hospital Fort Worth Southwest Kindred Hospital ArlingtonKindred Hospital West Kindred Hospital - MansfieldMesquite Rehabilitation Institute Mesquite Specialty HospitalMesa Springs Asana HospiceAtrium Medical Center Angel Hospice Trinity Terrace Are you an employee? Y NIf no, what is your relationship to the hospital/hospice employee? _______________________ ................
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