Address:______________________________________________________________
Telephone:___________________________Date of
Birth____________Age__________
High School
Name:_______________________________________________________
Current Grade:___________________(Only Grade
12 Qualifies) Current GPA_________
How did you hear about the Stormberg
Orthodontic Scholarship Program (teacher, school counselor, Stormberg
Orthodontics Employee, Patient, Website)?
___________________________________________________________________________
Attach Required 500 Word Essay:
In 500 words or more, attach a written essay
“Why Self-Confidence is So Important.”
Separately, list any additional information
about you, including special achievements
or activities, awards, hobbies, talents, or
anything you believe might be useful to
Stormberg Orthodontics in evaluating your
applications.
List extracurricular school and/or community
activities in which you participate.
Describe your role in each
activity____________________________________________
________________________________________________________________________________________________
Any
Questions:
Contact
Debbie Rolf, Marketing Coordinator
619-462-4462
drkurt@orthosandiego.com
Email