FLORIDA FOUNDATION OF DENTAL HYGIENE
AS/AA 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 tell us about your SAHDA activities, what your plans are for dental hygiene
practice after licensure, and how you feel this scholarship will benefit you in your role as a dental hygienist and
help you achieve your educational goals.
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