"*" indicates required fields Note:The Future of Healthcare Scholarship application is open from 1/18/24 through 3/31/24. Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY RaceAmerican Indian or Alaskan NativeAsianBlack of African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherGenderFemaleMalePrefer Not to SayPermanent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School AddressPlease enter the address of the school the scholarship will be used for that you will attend/that you are currently attending Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Indicate major/degree, certification/trade field you are seeking Are you currently enrolled in an upcoming semester?YesNoWhat date does your upcoming semester begin? MM slash DD slash YYYY Name of institutionPlease enter the name/address of the high school, college, other education institutions you last graduated from Dates of Attendance Diploma or Degree ReceivedHigh School DiplomaGEDAssociates DegreeBachelor's DegreeMastersTrade School CertificationIf previous college degree obtained what is the major/trade field and the degree/certification sought If you are a clinician please indicate your highest level of certification How did you learn about Maxim’s Scholarship Program?FacebookGoogleJob FairLinkedInMaxim BranchMaxim Company CommunicationReferralCurrent InstitutionOtherHave you ever been a Maxim employee in any capacity?YesNoIn the segment below please tell us about yourself, and why you should be selected to receive the scholarship and how it will help you? Also include what you hope to accomplish in your selected field, and how will you impact others with the education you acquire from medical training and/or healthcare studies?*Please provide any extracurricular activities that you are currently involved in. (This can include community service and work history).*Please select the category that best describes your application category?High School Graduate/Current College StudentNon-Traditional/Returning Student in Clinical Field or Healthcare IndustryPlease attach your most recent educational transcriptAccepted file types: docx, doc, rtf, txt, pdf, odt, Max. file size: 2 GB.Signature Date MM slash DD slash YYYY Consent I consent to having my name and photo shared for promotional purposes* *Notice of Use/Disclosure of Personal Information: Selected candidates will be recognized and highlighted for internal and external promotional purposes. These spotlights will be created and shared through multiple outlets, including, but not limited to, social media, Maxim’s web site, company newsletters, trainings, and other online and offline channels. Selected candidates will be informed of these activities in advance and will be given the opportunity to review all materials prior to publication. Participation in this activity is voluntary and individuals may decline participation at any time without any adverse effect to Applicant, except to the extent that action has been taken in reliance on this Authorization before its revocation. Any questions or concerns regarding this process or use/disclosure of personal information may be directed to Maxim’s Privacy Officer, in writing at: Maxim Healthcare Group, Attn: Privacy Officer, 7227 Lee Deforest Drive, Columbia, MD 21046. Δ
