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Family Scholarship Application

All items with a red asterisk * must be completed. If you do not know the correct response type in unknown or NA.
Certified Member's Personal Information
Last Name *
First Name *
Middle Name *
Date *	[dd-MMM-yyyy]
Home Address *
Home City *
Home State *
Home Zip Code *
Home Phone *
Email *
Date of Birth *
Marital Status *
Spouse's Name *
Number of Dependents *
Spouse's Occupation (if applicable) *
Dependant's Personal Information
Dependent Last Name *
Dependent First Name *
Dependent Middle Name *
Permanent State *
Dependent Date of Birth *
Permanent Address *
Permanent Zip Code *
Name of High School *
Permanent City *
High School City *
High School State *
College or University Presently Attending *
Undergraduate Major *
Undergraduate Minors *
Cumulative Grade Point Average (at time of application) *
Grade Point Scale *
Currently on Full Scholarship? *
Certified Member's Professional Information
Place of Employment *
Are you currently a member of the Southeast Athletic Trainers' Association? *
Number of years you have been a certified member of the NATA? *
Number of Years at Current Job? *
Number of years you have been a certified member of SEATA? *
NATA Membership Number *
If you have served in any volunteer position within the governing body of your professional state, district or national associations please list these titles below along with the years served.
Volunteer positions within the governing body of your professional state, district or national associations *
Certified Member's Personal and Professional Background
In the space provided, please give a brief biographical sketch of yourself. You may include the following: information on your family make-up, contributions to professional associations, community involvement, organizations to which you belong or have belonged, awards which you have previously won and jobs you have held.
Certified Member's Personal and Professional Background *
Dependant's Personal Background
In the space provided, please give a brief biographical sketch of yourself. You may include the following: why you merit this award, information on your school, social and/or church activities, achievement in your community, jobs you have held during summers or while attending college.
Dependant's Personal Background *
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