APPLICATION

GRACE E. & DANIEL W. PATRICK SCHOLARSHIP FUND

FOR FORMER PATIENTS OF

SPOKANE UNIT, SHRINERS HOSPITALS  FOR CHILDREN

NAME OF APPLICANT____________________________________________________________________

RESIDENCE_________________________________________________________________________

TELEPHONE_________________________ AGE_____ S.S.NO._____________________________

SCHOOL ADDRESS IF KNOWN______________________________________________________

x_____________________________________________________________________________________

SIGNATURE OF APPROVAL/PARENT OR LEGAL GUARDIAN

DATES YOU WERE A PATIENT IN THE SPOKANE UNIT-SHRINERS HOSPITAL

_____________________________________________________________________________________

STATE YOUR GENERAL PHYSICAL CONDITION_____________________________________

_____________________________________________________________________________________

NAME OF COLLEGE YOU WISH TO ATTEND__________________________________________

     ADDRESS_________________________________________________________________________

CAN YOU MEET ENTRANCE REQUIREMENTS?_______________________________________

WHAT COURSE DO YOU WISH TO PURSUE?__________________________________________

LENGTH OF COURSE_____________________________________________________

                                                 (QUARTERS)                       (SEMESTERS)                  (YEARS)

IS YOUR SCHOOL ON A QUARTERLY OR SEMESTER BASIS?_________________________

YOUR STATUS FOR THE COMING YEAR: FRESHMAN  SOPHOMORE  JUNIOR   SENIOR

                                                                                                                                           (CIRCLE ONE)

COST OF TUITION_________________________________________________________

                                                 (QUARTER)                         (SEMESTER)                        (YEAR)

WILL YOU RECEIVE FUNDS FROM ANY OTHER SOURCE:

   PARENT OR GUARDIAN                                               $_________________

   STATE ASSISTANCE PROGRAM                                $_________________

   FEDERAL ASSISTANCE PROGRAM                           $_________________

   ENDOWMENT                                                                    $_________________

   LOAN                                                                                     $_________________

   SELF EMPLOYMENT                                                        $_________________

DATE:  _______________________    ___________________________________________________

                                                                                                                        SIGNATURE OF APPLICANT

REFERENCE  (SHRINER IF POSSIBLE)                               REFERENCE (SHRINER IF POSSIBLE)

_________________________________                                      ____________________________

Address__________________________                                    Address_____________________

_________________________________                                    _____________________________

Telephone________________________                                    Telephone___________________

SUBMIT APPLICATIONS TO:

Shrine-Patrick Scholarship Fund,                    TELEPHONE:  (509) 624-2762

c/o El Katif Temple,                                                       FAX NO.   (509) 624-8333

West 1108 Riverside Avenue,

Spokane, WA        99201-1197