FLORIDA FOUNDATION OF DENTAL HYGIENE
ADVANCED DENTAL HYGIENE DEGREE SCHOLARSHIP APPLICATION FORM
Name _________________________________________________________________________________
Address ___________________________City ________________________State ______ Zip __________
Home Phone (________)________________________Work Phone (_________)_____________________
If currently employed, what is your occupation and salary? _______________________________________
______________________________________________________________________________________
College now attending ______________________________________ Current GPA ___________________
Previous education (include name of institution, location, year(s) attended or graduated, degree obtained):
______________________________________________________________________________________
______________________________________________________________________________________
Are you listed as someone’s financial dependent? ______________
Do you have financial dependents living with you? _____________ How many? ______________________
If you are a financial dependent, please complete the following:
Financial Supporter’s Name _________________________________________________________________
Address ___________________________________City _________________State ______ Zip ___________
Occupation _______________________________________ Annual Salary ____________________________
Are there other dependents in this household? ________How many? _______________
Have you received financial aid from other sources? ___________If yes, please specify: __________________
_________________________________________________________________________________________
Is there anything else you feel this Foundation should know when considering your application?_____________
__________________________________________________________________________________________
On a separate sheet of paper please list all ADHA/FDHA participation. Also please explain how additional education
will benefit you in your role as a dental hygienist and tell us where you plan to practice after completing your degree
and why.
I attest to the best of my knowledge that all of the above information is correct.
Applicant’s Signature __________________________________________Date ________________________
COMPLETED APPLICATIONS MUST BE RECEIVED BY SEPTEMBER 1 (Each school year)
Send original application and 3 copies to:
FFDH c/o Lisa Potter
P.O. Box 1285
Palmetto, FL 34220