www.AndyFutureRDH.com
Website Scholarship
Free National Board Exam Entry Form

Full Name:_______________________                                  Birth date: __________ 

Phone Number: _______________           Alternate Phone Number: ____________

Permanent Mailing Address	School Name and Address	

	

Expected Graduation Date:__________     Degree expected to earn:_______________  

Please list any activities, organizations, memberships, positions held and/or awards earned WHILE in the dental hygiene program below.  This is both scholastic and personal data.  

__________________________              ___________
Student Signature                                      Date

__________________________              ___________
Program Director Signature                           Date

www.AndyFutureRDH.com
Website Scholarship

Scholarship Requirements
•	Must be a member of the FutureRDH group hosted by AndyFutureRDH.com. For information and to join please go to FutureRDH group on Yahoo
·	Must be a current student and enrolled in an accredited dental hygiene program in the United States.
·	Be eligible to take the national board exam at any testing date during the 2005 calendar year.  
·	Be a member of SADHA and submit a photocopy of your membership card.
·	Submit an official college transcript.
·	Submit ONE photograph of yourself (or yourself in a group) participating in some type of dental related community service project, volunteer work or patient education.  This can be with a group of people, one person, or even displaying some type of poster in a public setting.   
·	Complete all areas of this application, including signature from program director and mail to the address below.

Application Deadline:  March 20th, 2005

Please mail completed application to:

Andy Codding, RDH
C/O www.AndyFutureRDH Scholarship
121 Robinhood Road
Rome, Georgia 30161