Naugatuck Valley Medical Scholarship Application

The deadline for submitting this application and all related materials, including standardized test scores, is April 1.

Personal Information

Name

Address

Phone

Date of birth

Academic Information

Academic Requirements:

GPA must be 3.5 or higher based on a 4.0 grade scale
SAT or ACT:

SAT:

Reading: 600
Writing: 600
Math: 600

ACT:

Score of 26 in English, Math, Science, and Reading

Send in one copy of SAT/ACT Score Sheet(s) along with a copy of your high school transcript to the address below. THIS IS REQUIRED.

William P. Silberberg, M.D.
31 Jenick Lane
Woodbridge, CT 06525-1935

High school attending Cumulative grade point average

Other Requirements

Note to Applicant: To be eligible for a scholarship, applicants must undertake a medically oriented or medical science oriented program at an accredited institution of higher learning, and must presently and during the scholarship period be a legal resident of Ansonia, Derby, Seymour, Shelton, Oxford, or Beacon Falls, Connecticut.

Schools applied to Planned major Planned career

List any scholastic honors or prizes List extracurricular activities (with dates) List work experience (with dates) List any college scholarships or grants awarded

Parents/Guardians

Father

Name Address Phone Occupation

Mother

Name Address Phone Occupation

Gross family income

$ per year

Approximate family debt (including mortgage)

Name and age of any siblings:

Any special financial costs, needs, or problems