• Scholarship Form

    Scholarship Form

  • 2022-2023 STUDENT ENROLLED IN AN ACCREDITED MEDICAL SCHOOL SCHOLARSHIP APPLICATION

    Scholarship applications will be reviewed quarterly. Deadlines for applications are: March 31, 2022; June 30, 2022; September 1, 2022; December 1, 2022.

    Late or incomplete applications will NOT be considered.

    Please submit this application with the following:

    • Three (3) letters of reference: an academic reference and two additional letters of recommendation from your pastor, colleagues, professional peers, etc.
    • An essay of at least 250 words in which you describe why you are pursuing the degree you’ve chosen and your career plans upon achieving your degree.
    • Copy of your notice of acceptance into the degree program or conference information.

    • Applicant must reside or originally be from the 11 counties Good Samaritan serves. 
      Indiana: Knox, Daviess, Pike, Greene, Martin, Sullivan and Gibson Counties
      Illinois: Lawrence, Wabash, Crawford and Richland Counties

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  • THIS SECTION FOR COLLEGE/UNIVERSITY APPLICANTS ONLY

    Please provide the name and address of the university/program in which you are presently enrolled, or to which you are applying. If you have received a student ID, please include it.

  • Name of University/Program:
    Student ID Number (If Available):    
    University/Program City, State, Zip:    
    Health care degree you are pursuing:   
    Date you began/will begin this curriculum (Month/Year):   
    Anticipated date of graduation (Month/Year):   
    Number of hours enrolled per semester/quarter:    
    Number of hours completed in program:    

    COLLEGE/UNIVERSITY GPA:         

  • For applicants attending an accredited college or university, a scholarship requirement is to maintain a 3.0 GPA. Please initial below to give Good Samaritan Foundation approval to access your mid-year and final cumulative GPA from your college/university during the upcoming academic year. (You must also authorize Good Samaritan Foundation on your records at your college/university.) *

  • Answer the following questions, providing information which corresponds with your present situation:

  • If you have attended college/university, list all financial assistance received, including amounts (grants, scholarships, student loans, etc.):

    Grants and Scholarships: $   $   
    Student Loans: $   $

  • List all financial assistance that you expect to receive for this academic year:

    Grants and Scholarships: $   $  $   
    Student Loans: $  $  $    

  • I hereby apply for a Good Samaritan Foundation Scholarship. I have read, and I understand, the terms of the scholarship award.


    If I receive a scholarship, I agree to comply with the requirements of the award. I will provide Good Samaritan Foundation with my student ID (if applicable), email address and photograph. I agree to grant Good Samaritan Foundation access to my financial information on record for the purpose of determining financial need as it applies to my application for a scholarship with the Foundation.

    I certify that my Reference Letters, Essay, Notice of Acceptance and Official Transcripts have been attached to this form, or will arrive via mail to:


    Good Samaritan Foundation
    Attn: Foundation
    520 S. Seventh St.
    Vincennes, IN 47591


    Scholarships will only be awarded to students in health care related fields of study. Late or incomplete applications will not be considered.

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