School of Medicine and Health Sciences

APPLICATION FOR A CULTURAL DIVERSITY TUITION WAIVER

Last Name
First Name
Address
City
State
Zip
Social Security Number
Phone Number
Please Check all that Apply:

______Culturally Diverse
______Enrolled Member of a Federally Recognized Indian Tribe
______Economically Disadvantaged
______American Indian with Documented Lineal Heritage

 Please indicate below why you should be considered for this waiver.