CDA Foundation Dental Assisting 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;
Transcript; and
Most Recent Tax Return.

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

Please select one of the following scholarship types that you are applying for (if applying for both scholarships, please submit only one application):

Maurice Amado Dental Assisting Scholarship Bettie Underwood Dental Assisting Scholarship Both the Maurice Amado AND Bettie Underwood Dental Assisting Scholarships

I. General Information

Application Date

Applicant's Name First Name Last Name

Home Address Street Street (cont.) City State Zip

Telephone E-mail Address

Are you an underrepresented minority or do you come from a disadvantaged background?

Yes No

Are you a US Citizen

Yes No

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

Upload File:

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

II. College or Program Information

School Name

School Address Street Street (cont.) City State Zip

You must be currently enrolled in a California dental program to qualify for this scholarship and be able to provide proof of enrollment.

Please upload your proof of enrollment here.

Upload File:

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

Year in School What dental assisting certificate or license are you pursuing? What is your long term career goal?

Maximum 1,000 characters. Characters used: 0.

Anticipated graduation date

You must be able to demonstrate academic achievement and provide proof by submitting your dental program transcripts.

Please upload your current dental program transcripts here.

Upload File:

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

III. Financial Information

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).

Tuition for school year (annual course enrollment and school admission fees only) Books and Supplies (annual costs) Living Expenses (entire family household annual costs) Other Total (Cumulative total of family household annual expenses)

Will you work during the school year

Yes No

If yes, how many hours/week 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)

Do you currently live with your parents?

Yes (indicate the annual amount you pay for room and board) No

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.

Have you applied for other scholarships, financial aid or grants?

Yes No

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

Upload File:

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

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

Employer #1

Employer Position

Employer Address Street Street (cont.) City State Zip

Employer Telephone Hours per week worked

Employed from

Employed to

Employer #2

Employer Position

Employer Address Street Street (cont.) City State Zip

Employer Telephone Hours per week worked

Employed from

Employed to

Employer #3

Employer Position

Employer Address Street Street (cont.) City State Zip

Employer Telephone Hours per week worked

Employed from

Employed to

Employer #4

Employer Position

Employer Address Street Street (cont.) City State Zip

Employer Telephone Hours per week worked

Employed from

Employed to

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

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.

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.

What are the total cumulative hours of volunteer services that you have provided within the last three years?

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.

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.

VI. Personal Statement

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.

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.

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.

Paint a picture of your academic achievements by describing to us your educational background and demonstrating your dental program academic challenges and successes.

Maximum 500 characters. Characters used: 0.

VII. Certification

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.

Electronic Signature (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.

Electronic signature (type full name):

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.

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CDA Foundation Dental Assisting Scholarship Application

I. General Information

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

II. College or Program Information

You must be currently enrolled in a California dental program to qualify for this scholarship and be able to provide proof of enrollment.

You must be able to demonstrate academic achievement and provide proof by submitting your dental program transcripts.

III. Financial Information

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).

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

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

Employer #1

Employer #2

Employer #3

Employer #4

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

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

VI. Personal Statement

VII. Certification

Electronic Signature (Required)

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