Dental Student Scholarship Application

Thank you for expressing interest in the CDA Foundation and its scholarship program. We appreciate you applying for our services which are available to benefit people who want to improve the oral health of all Californians.

Prior to beginning the online application process, please scan the following supporting documents and have them ready to upload as attachments (Word, Excel, PDF, etc.) to this application when prompted to do so later:

Proof of Hours of Volunteer Service (Please note that internships or any other non-paid services that are part of a program curriculum or requirement do not qualify as volunteer community service/leadership under this scholarship program.);
Proof of Enrollment;
Proof of Student in Good Academic and Ethical Standing with Dental School;
Most Recent Tax Return; and
Optional Letter of Recommendation.

During this application process, you will need to answer the questions by typing text, checking boxes/buttons, and where prompted, upload/download documents as attachments to this online application. All requested file uploads and downloads are required to complete your application. Once we have received your application, an automated receipt confirmation will be sent to you at the e-mail address provided below. Good luck!

Submission Criteria

Complete online application, attaching all supporting documents, and submit online.
Approval from CDA Foundation staff is required prior to accepting e-mailed applications. If you are experiencing difficulties submitting the online application, please contact the CDA Foundation staff via e-mail at jolene.murray@cda.org to request an alternative submission method and a Word document of the grant application will be sent to you for completion.

Incomplete applications are ineligible to receive an award.

Light Purple Shaded Areas are Required Fields

I. General Information

Application Date

Error: The "Application Date" is required.

Applicant's Name First Name Last Name

Error: The "Applicant's Name" is required.

Home Address Street Street (cont.) City State Zip

Error: The "Home Address" is required.

Are you a US Citizen
Yes No

Error: The "Are you a US Citizen" is required.

If no, please upload documentation of your naturalization or other proof of legal U.S. residency.

Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "If no, please upload documentation of your naturalization or other proof of legal U.S. residency." is required.
Telephone
Error: The "Telephone" is required.
E-mail Address
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II. Dental School Information

Error: The "II. Dental School Information" is required.
Dental School Name
Error: The "Dental School Name" is required.

Dental School Address Street Street (cont.) City State Zip

Error: The "Dental School Address" is required.

You must be currently enrolled in a California Dental School to qualify for this scholarship and be able to provide proof of full time enrollment.

Please upload your proof of enrollment here.
Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "You must be currently enrolled in a California Dental School to qualify for this scholarship and be able to provide proof of full time enrollment. " is required.
Year in Dental School
Error: The "Year in Dental School" is required.

You must be able to demonstrate that you hold a good academic and ethical standing by providing proof of this from your dental school.

Please upload proof from your dental school of your good academic and ethical standing.
Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "You must be able to demonstrate that you hold a good academic and ethical standing by providing proof of this from your dental school." is required.
What is your long term career goal as a dentist?
Maximum 1,000 characters. Characters used: 0.

Error: The "What is your long term career goal as a dentist?" is required.

Anticipated dental school graduation date

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III. Financial Information

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Please provide us with information on your family household income and financial needs. Base all figures on your entire family household estimated finances for the year (including your spouse, or parents if you are living with or a declared dependent of your parents).

Error: The "Please provide us with information on your family household income and financial needs. Base all figures on your entire family household estimated finances for the year (including your spouse, or parents if you are living with or a declared dependent of your parents).

" is required.
Tuition for school year (annual course enrollment and school admission fees only)
Error: The "Tuition for school year (annual course enrollment and school admission fees only)" is required.
Books and Supplies (annual costs)
Error: The "Books and Supplies (annual costs)" is required.
Living Expenses (entire family household annual costs)
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Other Expenses (not included above)
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Total (Cumulative total of family household annual expenses)
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Will you work during the school year
Yes No

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If yes, how many hours/week
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Estimated annual family household income for this academic year (including your spouse, or parents if living with or if a declared dependent of your parents)
Error: The "Estimated annual family household income for this academic year (including your spouse, or parents if living with or if a declared dependent of your parents)" is required.

Do you currently live with your parents?
Yes (indicate the annual amount you pay for room and board) No

Error: The "Do you currently live with your parents?" is required.

You must be able to provide a copy of your family household's most recent tax returns (including yours, and your spouse's or parents' if you live with them).

Please upload your most recent tax returns here.
Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "You must be able to provide a copy of your family household's most recent tax returns (including yours, and your spouse's or parents' if you live with them)." is required.

Have you applied for other scholarships, financial aid or grants?
Yes No

Error: The "Have you applied for other scholarships, financial aid or grants? " is required.

If yes, please upload financial aid or loan statement here.

Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "If yes, please upload financial aid or loan statement here." is required.

IV. Employment History (please begin with most recent employer)

Error: The "IV. Employment History (please begin with most recent employer)" is required.

Employer #1

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Employer
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Position
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Employer Address Street Street (cont.) City State Zip

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Employer Telephone
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Hours per week worked
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Employed from

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Employed to

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Employer #2

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Employer
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Position
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Employer Address Street Street (cont.) City State Zip

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Employer Telephone
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Hours per week worked
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Employed from

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Employed to

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Employer #3

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Employer
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Position
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Employer Address Street Street (cont.) City State Zip

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Employer Telephone
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Hours per week worked
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Employed from

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Employed to

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Employer #4

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Employer
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Position
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Employer Address Street Street (cont.) City State Zip

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Employer Telephone
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Hours per week worked
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Employed from

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Employed to

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V. Community or Volunteer activities over the past three years.

Error: The "V. Community or Volunteer activities over the past three years. " is required.

You must be able to demonstrate volunteer service within the last three years and provide documented proof in order to be considered for this scholarship. Please note that internships or any other non-paid services that are part of a program curriculum or requirement do not qualify as volunteer community service/leadership under this scholarship program.

Error: The "You must be able to demonstrate volunteer service within the last three years and provide documented proof in order to be considered for this scholarship. Please note that internships or any other non-paid services that are part of a program curriculum or requirement do not qualify as volunteer community service/leadership under this scholarship program.

" is required.
Please briefly describe the type of volunteer services you have provided within the last three years, including the name of the organizations that the service was provided for, the hours served, and the contact name and phone number.
Maximum 750 characters. Characters used: 0.

Error: The "Please briefly describe the type of volunteer services you have provided within the last three years, including the name of the organizations that the service was provided for, the hours served, and the contact name and phone number." is required.
What are the total cumulative hours of volunteer services that you have provided within the last three years?
Error: The "What are the total cumulative hours of volunteer services that you have provided within the last three years?" is required.

You must be able to provide documented proof of the hours of volunteer services that you described above.

Please upload your documented proof of volunteer services here.
Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "You must be able to provide documented proof of the hours of volunteer services that you described above." is required.
If you have held positions of leadership, received any awards or been recognized for your involvement, please be sure to describe below or enter N/A if not applicable.
Maximum 1,000 characters. Characters used: 0.

Error: The "If you have held positions of leadership, received any awards or been recognized for your involvement, please be sure to describe below or enter N/A if not applicable." is required.

VI. Personal Statement

Error: The "VI. Personal Statement" is required.
Tell us more about your career goals and what you hope to accomplish through your education, draw upon life experiences from all areas of your life.
Maximum 500 characters. Characters used: 0.

Error: The "Tell us more about your career goals and what you hope to accomplish through your education, draw upon life experiences from all areas of your life." is required.
Paint a picture of your financial need by demonstrating to us of your financial background and current situation (explain level of financial hardship).
Maximum 500 characters. Characters used: 0.

Error: The "Paint a picture of your financial need by demonstrating to us of your financial background and current situation (explain level of financial hardship)." is required.
Paint a picture of your volunteer community services by demonstrating to us your experiences, lessons taken from the experiences, and future aspiration to provide volunteer services.
Maximum 500 characters. Characters used: 0.

Error: The "Paint a picture of your volunteer community services by demonstrating to us your experiences, lessons taken from the experiences, and future aspiration to provide volunteer services." is required.
Paint a picture of your academic achievements by describing to us your educational background and demonstrating your dental school academic challenges and successes.
Maximum 500 characters. Characters used: 0.

Error: The "Paint a picture of your academic achievements by describing to us your educational background and demonstrating your dental school academic challenges and successes." is required.

Optional - Please upload your letter of recommendation here.

Upload File:
Please keep individual attachments under 300k. Please click here for scanning tips.

Error: The "Optional - Please upload your letter of recommendation here." is required.

VII. Certification

Error: The "VII. Certification" is required.

I acknowledge that the decisions of the Scholarship Committee and the CDA Foundation are final and that this is a competitive selection process. I certify that the information provided is complete and accurate to the best of my knowledge. I understand that this application may be denied or withdrawn if it is incomplete and/or if any information reported is found to be intentionally misleading, inaccurate or fraudulent.

I authorize the CDA Foundation to use my name and/or photo for the purpose of community and public relations.

Error: The "I acknowledge that the decisions of the Scholarship Committee and the CDA Foundation are final and that this is a competitive selection process. I certify that the information provided is complete and accurate to the best of my knowledge. I understand that this application may be denied or withdrawn if it is incomplete and/or if any information reported is found to be intentionally misleading, inaccurate or fraudulent.

I authorize the CDA Foundation to use my name and/or photo for the purpose of community and public relations.
" is required.

Electronic Signature (Required)

Error: The "Electronic Signature (Required)" is required.

Please check the electronic signature button, type in your first and last name in the space provided, and click the button on this page labeled "Submit" to certify that all statements made in this application and its attachments are complete and accurate to the best of your knowledge, and to authorize the CDA Foundation to verify the information provided in this application.

Error: The "Please check the electronic signature button, type in your first and last name in the space provided, and click the button on this page labeled "Submit" to certify that all statements made in this application and its attachments are complete and accurate to the best of your knowledge, and to authorize the CDA Foundation to verify the information provided in this application.
" is required.

Electronic signature (type full name):

Error: This field is required.

By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.

Error: The "By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.

" is required.

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