Jerry C. Waggoner Medical Foundation Scholarship

I certify that the information in this application is true and accurate. I further certify that if, for any reason subsequent to receiving a scholarship award, I elect to substantially alter my proposed study plan, I will immediately inform the Jerry C. Waggoner Medical Foundation. I understand that, if requested, I will return the money paid on my behalf. By submitting this application and signing below, I authorize the Jerry C. Waggoner Medical Foundation to publish my name and picture in any local media.

By selecting the "I Agree" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Agree" you consent to be legally bound by this Agreement's terms and conditions.