Date:_________________

Name:___________________________________________________________________

Address: ________________________________________________________________

Date of Birth:_____________________________

Phone number:___________________________

Email address:____________________________

Name of organization hosting / sponsoring the public health / mission event:

______________________________________________________________________________________________________________.

Address:_____________________________________________________________________________________________________.

Email:________________________________. Phone number:_______________________. Website:______________________.

Contact person: ________________________________________. Name of team leader and contact information (if different):

_________________________________________________________________________________________________________________________________________________________________________

1. Please indicate the dates and location of the public health / mission event you are needing funds 

for and describe why you are interested in attending:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________ 

2. Have you previously participated in events like this?____________ If yes, please explain:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

3. What do you hope to accomplish through participation?

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

4. Please describe your educational / career background and if you endeavor to be serving as a student /

trainee, professional, or support staff:  _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

5. Please indicate the total cost of the trip $ __________.  How much have you (will you be able to) save

towards the trip?___________.  Have you received any other donations for this trip?________. If yes, how

much and from whom?____________________________________________________________________________.  Please

indicate what you are needing assistance with (such as air fare,  travel,  lodging) and how much you are

requesting: ________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

6. If HPGF is able to contribute towards your trip, can HPGF donate directly to the team leader or

organization arranging the trip?_________. 

7. Please list any community service (volunteer, civic, church) activities that you participated in during the last 4 years.

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

8. Are you bilingual?_______. If yes, what languages_________________________________________________________.

9. Please describe any leadership roles you have had and any gifting’s, training or talents and anything else you would like to share:

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

If you receive a HPGF scholarship would you be willing to write a short one or two paragraph report / testimony of your experiences on the trip that could be published on this website?___________.

I certify the information provided is accurate to the best of my knowledge and understand and that falsification may result in appropriate penalties. 

Signature___________________________________________ Full Name: ____________________________________ Date:____________

Please send this application to JNCMissions@gmail.com, along with a head and shoulders picture for identification and that may be used in publication.  In the subject line put “Scholarship Request.”