SANKEN-HATZ SCHOLARSHIP PROGRAM

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1 SANKEN-HATZ SCHOLARSHIP PROGRAM TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES. Completeness and neatness insure your application will be reviewed properly. FOR FOUNDATION USE ONLY I.D. #: Dear Scholarship Applicant: Thank you for your interest in the Sanken-Hatz Scholarship Program (SHSP) provided by the GRHS Foundation for members of the Glencoe Regional Health Services (GRHS) service area as determined by the selection committee. Applicants may be high school seniors, high school graduates or vocational, technical school, college undergraduates or graduate students and are enrolled or planning to enroll in a full-time course of study in an approved healthcare career at an accredited vocational or technical school, college or university. The GRHS Foundation administers the program. Every complete application received by the required deadline will be given a fair and careful evaluation. All information will be held in strict confidence by SHSP. Approximately eight weeks following the application deadline, you will be notified whether or not you are selected as a recipient. All applications become the property of SHSP and cannot be returned. THINGS TO REMEMBER IN APPLYING FOR A SCHOLARSHIP The application postmark deadline is March 31 st. If March 31 st falls on a Sunday, the postmark deadline is April 1 st. A current official transcript is required and must be submitted with the application. Online transcripts and grade reports are not acceptable. Two applicant appraisal forms are required. One appraisal form must be from a current academic reference. Appraisal forms from family members are not acceptable. Appraisal forms can be included with the application or mailed directly to the Foundation by the reference. Appraisal forms must be postmarked by March 31 st. If March 31 st falls on a Sunday, the postmark deadline is April 1 st. Carefully review your completed application before it is submitted. SHSP reserves the right to process only those applications found to be complete by the application postmark deadline. YOU are responsible for forwarding all required information. APPLICANT DATA Last Name _ First Name Middle Initial _ Permanent Home Mailing Address Apartment # _ City State Zip Code Date of Birth / / Telephone ( ) Address Please indicate your gender (for statistical purposes only) Male Female HIGH SCHOOL School Name Graduation Date: Month Year or PRIOR COLLEGE DATA City State Telephone ( ) POST- Name of post-secondary school you plan to attend. (if unknown, please list in order of preference the schools to which you have applied.) SECONDARY Use official school names. Do not use abbreviations. SCHOOL DATA City State City State Community/Technical College or Trade School 4 yr. College or University Graduate/Professional School Year in post-secondary program next school year: 1 st 2 nd 3 rd 4 th 5 th 6 th 7 th 8 th Other Major or course of study Anticipated date of graduation Month Year Anticipated career goal/profession If space provided in any section is inadequate, you may continue on additional sheets of paper using the same format. DO NOT repeat information already reported on the application form. Your name, address and name of this scholarship program should be included on all attachments.

2 WORK EXPERIENCE Describe your work experience during the past four years (e.g., food server, babysitting, lawn mowing, office work). Indicate dates of employment for each job and approximate number of hours worked each week. Employer/Position From - Mo/Yr To - Mo/Yr Hours per week ACTIVITIES, AWARDS and HONORS List all school activities in which you have participated during the past four years (e.g., student government, music, sports, etc.). List all community activities in which you have participated without pay during the past four years (e.g. Boy/Girl Scouts, hospital volunteer, Special Olympics). Note all special awards, honors and offices held. Indicate whether high school or college activities. Activity No. of Years Partic. Special Awards, Honors Offices Held Activity No. of Years Partic. Special Awards, Honors Offices Held GOALS Describe your future career goals. Where do you see yourself in ten years? UNUSUAL Please describe how and when any unusual family or personal circumstances have affected your achievement in school, work CIRCUMSTANCES experience, or your participation in school and community activities.

3 TRANSCRIPT INFORMATION An official transcript of grades must be sent with this application. Online transcripts and grade reports are not acceptable. 1. Students currently or previously enrolled in college or vocational-technical school must include all college or vo-tech transcripts of grades. (Completion of the following section is not necessary.) 2. High school seniors and students who have completed less than one full quarter or semester of post-secondary education must include a high school transcript of grades and have the following section completed by the appropriate school official. (A clear explanation of the school's grading scale must also be submitted.) Rank Cumulative GPA PSAT SAT ACT Applicant ranks in a class of Percentage rank Weighted: / 4.0 Unweighted: / 4.0 Verbal Math Verbal Math English Math Reading Science Composite School Official's Name (please print) Telephone Address City State Zip School Official's Signature Date Title APPLICATION CHECKLIST The student is responsible for submitting all materials to SHSP on time. This application for a scholarship becomes complete and valid only when SHSP has received all of the following materials: Student Application Current Complete Transcript(s) of Grades (including grading scale) Two Applicant Appraisal Forms Postmark deadline is March 31 st If March 31 st falls on a Sunday, postmark deadline is April 1 st. All materials, including transcript, must be addressed to: Sanken-Hatz Scholarship Program GRHS Foundation 1805 Hennepin Ave. North Glencoe, MN CERTIFICATION Sanken-Hatz Scholarship Program Committee has the sole responsibility for selecting recipients based on criteria as set forth in the program s descriptive brochure. This application becomes the property of SHSP. (It is recommended that you keep a copy for your own files.) I acknowledge decisions made by the Sanken-Hatz Scholarship Program Committee are final. I certify that I meet the basic eligibility requirements of the program as described in the brochure and that the information provided is complete and accurate to the best of my knowledge. If requested, I agree to give proof of information I have given on this form. Falsification of information may result in termination of any scholarship granted. Applicant s Signature Date AWARDS Scholarships are awarded for the full academic year and dispersed equally over two semesters. Students with one semester of coursework remaining will have the award prorated. Awards granted will be addressed to both the student and the school of which he or she is attending. It is extremely important that each award recipient notify the GRHS Foundation of any changes in educational location, address and major. In some instances, course changes may disqualify you from receiving future award benefits. Address and educational institution updates not reported to the Foundation may delay delivery of your award.

4 SANKEN-HATZ SCHOLARSHIP APPLICANT APPRAISAL FORM Applicant: This appraisal should be completed by a high school or college counselor, academic advisor, instructor/professor, or a work supervisor who knows you well. Appraisals from family members are not acceptable. Appraiser: You have been asked to provide information in support of this application. Please give immediate and serious attention to the following statements. When complete, please return to the applicant. If you prefer, you may return to the applicant in a sealed envelope or send directly to the Foundation. A letter of recommendation does not replace this section, but may be included with the form if desired. Please circle applicable responses below: The applicant's choice of a post-secondary extremely very moderately educational program is appropriate appropriate appropriate inappropriate Unknown The applicant's achievements reflect his/her ability extremely well very well moderately well not well Unknown The applicant is able to seek, find, and use extremely well very well moderately well not well Unknown learning resources The applicant demonstrates curiosity and initiative extremely well very well moderately well not well Unknown The applicant demonstrates good problem-solving extremely well very well moderately well not well Unknown skills, follows through, and completes tasks The applicant's respect for self and others is excellent good fair poor Unknown The applicant's ability to set realistic and attainable excellent good fair poor Unknown goals is The quality of the applicant's commitment to excellent good fair poor Unknown school and/or community is Comments: Applicant s Name Appraiser s Name Relationship to Applicant/Title Organization Signature Date Telephone ( ) Sanken-Hatz Scholarship Program ~ GRHS Foundation ~ 1805 Hennepin Ave. N. ~ Glencoe, MN 55336

5 SANKEN-HATZ SCHOLARSHIP APPLICANT APPRAISAL FORM Applicant: This appraisal should be completed by a high school or college counselor, academic advisor, instructor/professor, or a work supervisor who knows you well. Appraisals from family members are not acceptable. Appraiser: You have been asked to provide information in support of this application. Please give immediate and serious attention to the following statements. When complete, please return to the applicant. If you prefer, you may return to the applicant in a sealed envelope or send directly to the Foundation. A letter of recommendation does not replace this section, but may be included with the form if desired. Please circle applicable responses below: The applicant's choice of a post-secondary extremely very moderately educational program is appropriate appropriate appropriate inappropriate Unknown The applicant's achievements reflect his/her ability extremely well very well moderately well not well Unknown The applicant is able to seek, find, and use extremely well very well moderately well not well Unknown learning resources The applicant demonstrates curiosity and initiative extremely well very well moderately well not well Unknown The applicant demonstrates good problem-solving extremely well very well moderately well not well Unknown skills, follows through, and completes tasks The applicant's respect for self and others is excellent good fair poor Unknown The applicant's ability to set realistic and attainable excellent good fair poor Unknown goals is The quality of the applicant's commitment to excellent good fair poor Unknown school and/or community is Comments: Applicant s Name Appraiser s Name Relationship to Applicant/Title Organization Signature Date Telephone ( ) Sanken-Hatz Scholarship Program ~ GRHS Foundation ~ 1805 Hennepin Ave. N. ~ Glencoe, MN 55336

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