Scholarship Amount
Awarded scholarships will be in the amount of at least $1,500.
Eligibility
1. Applicant must be a resident of Ohio.
2. Applicant must be entering at least the second year of dental
school at an ADA accredited university during Fall 2021.
3. Applicant must be a member of ASDA.
Requirements
Students applying for an ODAF Dental Student Scholarship must:
1. Show their current financial status, verified by the school’s
financial aid office.
2. Provide a completed application with all requested information
included. Incomplete, illegible or late applications will not be
reviewed.
3. Include two letters of recommendation; see section V for
information on letter of recommendation requirements.
4. Essay portions must be typed and not handwritten.
5. Include Curriculum Vitae.
6. Completed application must be received by the deadline.
Past scholarship winners, as long as they meet all eligibility
requirements, can apply multiple years in a row for the Dental Student
Scholarship.
Named Scholarships
The ODA Foundation also awards several named scholarships
including the Darryl Dever Advocacy Scholarship, Forward Ever
Scholarship, and Dr. E. Karl Schneider II Humanitarian Scholarship.
The decisions for these awards will be based on the dental student
scholarship application. There is no separate application for these
special awards.
Deadline
The completed application and required documentation must be
received at the ODA Foundation office by June 23, 2021 at 5 p.m.
All scholarship forms must be sent to:
ODA Foundation
1370 Dublin Road
Columbus, OH 43215
OR
Emailed in a single email to:
Notification
Applicants will be notified if they will receive an ODAF scholarship no later than September 3, 2021.
Questions
For questions about the scholarship application, eligibility or requirements, contact the ODA Foundation at 614-
486-2700 or Carley@oda.org.
About the ODA
Foundation
The Ohio Dental Association
Foundation is a 501(c)(3) Ohio
charity and is the philanthropic arm
of the Ohio Dental Association. It is
governed by a Board of Trustees
elected by the Executive
Committee of the Ohio Dental
Association.
ODA Foundation Mission
The Ohio Dental Association
Foundation mission is to improve
the oral health of the citizens of
Ohio and to enhance the dental
profession in Ohio.
ODA Foundation Focus
The ODA Foundation supports a
strong dental education
environment in Ohio. The
scholarship program furthers the
profession of dentistry by attracting
the highest caliber of potential
dental professionals. Visit
www.oda.org
to learn more.
Please note: The Scholarship
Review Committee will review your
application and may call you for a
personal interview.
DENTAL STUDENT
2021 SCHOLARSHIP APPLICATION
1
Instructions
Complete all sections of this application. Please type or clearly print the information.
All application materials must be received at the ODA office no later than June 23, 2021 at 5 p.m. Applicants must be
Ohio residents and currently at full-time student status within their program. Incomplete, illegible or late applications will
not be reviewed.
Please complete the checklist below carefully when preparing your application and copy all materials for your files.
Students who submit complete applications will be contacted by phone, email or letter by September 3, 2021 informing
them if the scholarship request has been funded or denied. In order to evaluate your application, all items must be
completed.
I. General Information
II. Financial sketch
III. Biographical sketch
Curriculum Vitae
IV. Financial Needs Assessment-Student Status
IRS 1040 forms (student applicant and spouse, if applicable)
V. Reference list
Letter of recommendation from one ODA member dentist on their business/professional letterhead
Letter of recommendation from a second ODA member dentist or a member of the applicant’s community who
can speak to applicant’s community involvement, leadership or advocacy experiences
VI. Financial Needs Assessment-Financial Aid (completed by school financial aid officer)
VII. Academic Achievement Record (completed by school official)
I. General Information
Applicant’s Name: Date of Birth:
University Student ID number:
Address (during school year):
City: State: Zip:
Are you legally an Ohio resident? Yes No Number of years applicant has been an Ohio resident:
Home Address (if different):
City: State: Zip:
Email: Cell Phone:
Which address should we mail to in September 2021? Home address Address during school
High school attended, city/state and graduation year:
Undergrad school attended, city/state and graduation year:
Dental School attending:
Class level in September 2021: D2 D3 D4
Are you currently a member of American Student Dental Association? No Yes, ASDA number:
If applicant received an ODAF scholarship before, what year(s) and amount(s):
Honors and Awards:
2
II. Student Applicant Financial Sketch
Please answer the questions below to provide additional information related to your financial need. Limit your responses
to no more than the space provided. THIS SECTION MUST BE TYPED INTHE SPACE PROVIDED FOR EACH
QUESTION.
STUDENT APPLICANT FINANCIAL SKETCH
1. Will you be employed while in school or on break? If so, what type of job, how many hours and do you expect this
to defray the cost of education and/or living expenses? If you are not employed, please explain why not.
2. How much student debt (dental school debt only) do you expect to incur and what are your plans for paying it
down?
3. Do you have other financial obligations not reflected in this application and how do they impact your financial
need?
3
III. Biographical Sketch
Please respond to the questions below. Limit your responses to no more than the space allotted. Not answering a
question or stating “not applicable” is not an option. Please also attach a Curriculum Vitae. THIS SECTION MUST BE
TYPED IN THE SPACE PROVIDED BELOW.
1. Are you a member of any student dental organizations (including ASDA)? If yes, please list organizations and
describe your involvement with each.
2. Have you had any involvement with the ODA or ADA, such as attending ODA Annual Session, Street of Dreams,
or ODA council meetings? Please list your experiences and explain any involvement beyond general attendance.
4
3. What is your volunteer or community experience over the past four years? Please include any community, school-
related or other such experience including with the ODA/ADA, and describe your level of involvement in each.
(Answers to this question will help the review committee determine the recipient of the annual Dr. E. Karl
Schneider Humanitarian Scholarship.)
4. What involvement have you had in advocacy efforts such as Day at the Statehouse or Student Lobby Day?
(Answers to this question will help the review committee determine the recipient of the annual Darryl Dever
Advocacy Scholarship.)
5
5. Have you taken on any leadership roles in organized dentistry, dental school, volunteer activities or in your
community? (Answers to this question will help the review committee determine the recipient of the annual
Forward Ever Scholarship.)
6. How have the experiences you described in Biographical Sketch Questions 1 – 5 influenced you in life and in your
decision to pursue a dental career?
6
7. Why did you decide to pursue a career in dentistry?
8. How do you see yourself fulfilling the ODA Foundation’s mission when you are a practicing dentist?
9. What are your post graduate personal and professional goals for your first 5 years out of school?
10. Do you plan to practice dentistry in Ohio? If yes, explain why. If no, explain why not.
7
IV. Financial Needs Assessment – Student Status
The applicant must complete this section and include the following financial document (please black out social security
numbers):
• Most current IRS 1040 forms for student (and spouse if married). If you did not file taxes in 2020, did not have
any gross income in 2020 and are unmarried, you may omit the IRS 1040 form from your application.
Marital Status: Single Married Divorced Separated Widowed
1. Are you single, head of household? Yes No
2. Do you have children who receive more than half their support from you? No Yes How many?
3. Do you have dependents other than children/spouse who receive more than half their support from you?
No Yes
If Yes, explain:
Student’s Adjusted Gross Income (2020): $
Spouse’s Adjusted Gross Income (2020, if married): $___________________
Student’s (and spouse’s if married) Current Net Worth: $
Did you file taxes in 2020? Yes No
V. Reference List with Letters of Recommendation
The ODA Foundation requires two letters of recommendation. One letter must be from an ODA member dentist (such as
a mentor, childhood/family dentist, dentist from shadowing experiences or volunteer activities, or faculty member). The
second letter should either be from a second ODA member dentist or a member of the applicant’s community who can
speak toward the applicant’s community involvement, leadership or advocacy experiences (such as a community leader,
current or former employer, mentors, etc). Only one letter of recommendation can be from a dental school faculty
member. Family members cannot provide letters of recommendation. Each reference should type a letter of
recommendation on their professional letterhead and sign their letter. (Electric signature will be accepted) The letter can
either be provided to the applicant in a sealed envelope to include in their scholarship application, or the reference can
mail the letter to 1370 Dublin Rd., Columbus, OH 43215, fax to 614-486-0381 or lastly the reference can email the letter
directly to
Carle[email protected]g by June 23, 2021 at 5pm. Before asking for a reference, check to make sure a dentist is
an ODA member by visiting the ODA website at http://oda.org/account/members/ or email [email protected]
Please provide the names of the two individuals providing recommendation letters:
ODA member dentist:
Name: Relationship to applicant:
Second ODA member dentist or community member:
Name: Relationship to applicant:
Applicant Statement
I hereby affirm that all of the information supplied by myself and representatives of the university is correct and that I am
an Ohio resident currently enrolled in an accredited dental program. I understand that misrepresentation, fraud or
omission of facts is cause for disqualification or suspension of a scholarship.
Applicant’s Signature Date
8
VI. Financial Needs Assessment – Financial Aid
To the Applicant:
The ODA Foundation requests its Financial Needs Assessment- Financial Aid Form be signed and submitted to your
school’s financial aid office. The completed form must be included in the student’s application, not mailed separately. If
submitting the application electronically, the applicant can also request that the Financial Aid office send the completed
form directly to the applicant in a PDF format. This PDF can then be attached to the email submission of the application. If
your financial aid office cannot send it to you via email you can scan and upload the completed document to your
computer and attach it to your submission email. The financial aid office will be responsible for completing this form.
I hereby authorize the release of my Financial Needs Assessment to the ODA Foundation only for the purpose of
determining my financial need. I understand the information will be kept strictly confidential and that the ODAF may
request additional information from the Financial Aid Office related to this application.
Applicant Signature
Applicant Printed Name Date
To the Financial Aid Officer:
The student named above is applying for the ODA Foundation Dental Student Scholarship. In order to consider this
student’s application, it is necessary to have this Financial Needs Assessment Form completed. You can send/give the
completed form directly to the student.
Name of Applicant:
Is the applicant an Ohio resident? Yes No
Is student eligible for student loan assistance? Yes No
A. School Expenses for 2021/22 school year B. Financial Resources
(Do not include housing) Source Amount
Tuition: $ Scholarships/Grants: $
Fees: $ Family Contribution: $
Books: $ Employment Earnings: $
Supplies: $ Other Income (incl. $
spouse:)
Subtotal of $ Subtotal of Financial Resources $
2021/22 School Expenses Summary Total
C. Financial Loans: Source Eligible Amount 1. Indicate: Subtotal of
Loan Received: $ School Expenses (A) $
Loan Received: $ 2. Subtract: Subtotal of
Loan Received: $ Financial Resources (B) $
Loan Received: $ 3. Equals:
Subtotal of Financial Loans $ Unmet Financial Need $
List other scholarships/grants and amounts awarded for the 2021/22 school year:
Signature
Financial Aid Officer’s Signature Date
Financial Aid Officer’s Printed Name Title
School Name Phone Number
9
VII. Academic Achievement Record
T
o the Applicant:
To consider and evaluate this application, the Academic Achievement Record Form must be signed by the applicant and
completed by a school official and stamped with the school’s official seal. The completed form must be included in the
student’s application, not mailed separately to the ODA Foundation. If submitting the application electronically, the
applicant can also request that the Financial Aid office send the completed form directly to the applicant in a PDF format.
This PDF can then be attached to the email submission of the application. If your financial aid office cannot send it to you
via email you can scan and upload the completed document to your computer and attach it to your submission email. The
financial aid office will be responsible for completing this form.
I hereby authorize the release of my academic records to the ODA Foundation, only for the purpose of evaluating my
application for the Dental Student Scholarship.
Applicant’s Signature
Applicant’s Printed Name Date
To the Admissions Official:
The student named above is applying for the ODA Foundation Dental Student Scholarship. In order to consider this
student’s application, it is necessary to have this Academic Achievement Record Form completed by a school official in its
entirety and stamped with the school’s official seal.
Dental Program (school enrolled): School Official Seal
Year of Graduation:
Student is enrolled in Fall 2021 courses: Yes No
Enrollment Status: Full-Time Part-Time
*Most Recent Cumulative GPA:
*Class Ranking:
*Note: Please calculate GPA on a 4.0 scale.
Signature
School Officer’s Signature Date
School Officer’s Printed Name Title
School Name Phone Number
