NURSING EDUCATION ASSISTANCE PROGRAM 2015 Nursing Scholarship Application

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1 NURSING EDUCATION ASSISTANCE PROGRAM 2015 Nursing Scholarship Application Dear Nursing Scholarship Applicant, The Scott & White Nursing Scholarship Program provides support for the education of nurses in Central Texas. Applications are accepted between April 15 and July 15, Please provide all requested items in the checklist. Applications will NOT be considered if they are turned in after July 15, missing any item from the checklist, and/or submitted with items not on the checklist. Top applicants will be interviewed as part of the selection process. Checklist Application for Nursing Scholarship Program Most recent academic transcript (unofficial is acceptable) Professional reference as required (instructions found on pg 5&6) Recommendation from Supervisor (S&W employee only) Documentation that you are enrolled in a School of Nursing Page 1 of 8

2 I. PERSONAL INFORMATION: A. Name: Address: _ Permanent Address: City: State: Zip: Home Telephone: ( ) Work Telephone: ( ) Cell Telephone: ( ) B. Are you a United States Citizen? YES NO C. Are you a natural born US Citizen? YES NO D. Are you authorized to work in the United States? E. Have you served in the US armed forces? YES NO F. Most current GPA: G. Nursing school you are planning on attending: _ H. Nursing Program you wish to complete: LVN LVN to ADN ADN ADN to BSN BSN MSN Doctorate I. Nursing program enrollment date (month & year) J. Nursing program graduation date: (month & year) DO NOT CHANGE THE FORMAT OF THIS FORM! ALL APPLICATIONS MUST BE PRINTED AND THEN COMPLETED!!! ONLY USE THE SPACE PROVIDED!!!! DO NOT ADD EXTRA PAGES OR LETTERS!!!! Page 2 of 8

3 II. Education and Experience: A. Prior education: School(s) attended: Name of School Program Emphasis Dates B. Are you a member of a professional nursing or allied health organizations? YES _ NO If yes please list the names of the organizations: C. Do you hold a current State of Texas Nursing License? Yes (if yes, please answer questions 1 and 2) 1. Type of License _ RN LVN 2. Nursing License Number: D. Employed at Scott & White: Date of Hire: Position: Department / Unit: Circle One: FULL TIME PART TIME PRN No Scott &White work history: Dept / Unit Dept / Unit Dept / Unit Date Date Date Page 3 of 8

4 III. PERSONAL GOALS A. Describe what attracted you to the nursing profession. B. How will you advance the profession of nursing? C. Where do you see yourself in five years after graduation? D. Describe your ideal job upon graduation and include any desired specialties. E. Explain how receiving a scholarship will enhance your nursing studies. Page 4 of 8

5 IV. Professional Reference One - (Previous Colleague or Academic Faculty) A. To be completed for Scott & White and non-scott & White Employees Name of Candidate: Please rate applicant on items 1 through 4 and provide comments as needed: Scale: 1 lowest 5 - highest 1. Applicant has a strong work ethic. _ 2. Applicant demonstrates excellent leadership skills. 3. Applicant has an exceptional ability to relate to others. 4. Applicant has the ability to positively impact the profession of nursing. 5. How long have you known the candidate and in what capacity? 6. Please make any additional comments concerning the candidate that you feel would qualify him/her for consideration. Your name: Place of Employment or Organization: Title: Address: Home Phone: ( ) Work Phone: ( ) Page 5 of 8

6 V. Professional Reference Two - (Previous Colleague or Academic Faculty) A. To be completed for non-scott & White Employees ONLY! Name of Candidate: Please rate applicant on items 1 through 4 and provide comments as needed: Scale: 1 lowest 5 - highest 2. Applicant has a strong work ethic. _ 2. Applicant demonstrates excellent leadership skills Applicant has an exceptional ability to relate to others. 4. Applicant has the ability to positively impact the profession of nursing. 5. How long have you known the candidate and in what capacity? 6. Please make any additional comments concerning the candidate that you feel would qualify him/her for consideration. Your name: Place of Employment or Organization: Title: Address: Home Phone: ( ) Work Phone: ( ) Page 6 of 8

7 VI. S&W EMPLOYEES ONLY: RECOMMENDATION FROM SUPERVISOR I recommend (Name of applicant) for the Scott & White Nursing Scholarship. He/She has been in the employment of Scott & White since (Date of Hire) and has exhibited an overall satisfactory performance rating. Comments: Questions for Supervisor Scale: 1 lowest 5 - highest 1. Attendance 2. Problem Solving 3. Team Player 4. Would you hire into future nursing position? Yes No Supervisor Name: Supervisor Signature: Supervisor Unit and Title: Phone Number: Date: Page 7 of 8

8 VII. TERMS OF NURSING EDUCATION ASSISTANCE PROGRAM If I receive a nursing scholarship, I will and do agree to the following conditions: 1. To provide copies of grades within two weeks of the end of the semester. Grades can be mailed to address provided below or hand delivered to the Nursing Professional Development, 4 th floor of Conference Center, Scott & White Memorial Hospital campus. 2. Maintain current address, phone and information during the duration of the scholarship program. any changes to Naomi Thompson at 3. Provide documentation of enrollment in nursing school at the beginning of each Semester (Fall 2015 and Spring 2016). This documentation can either be mailed to the address below or hand delivered to: Nursing Professional Development MS26A431 Signature of applicant: Date signed: Please send completed applications to: Naomi Thompson Administrative Supervisor Nursing Professional Development MS-26-A431 Scott & White Memorial Hospital 2401 South 31 st Street Temple, Texas Contact information Telephone: Page 8 of 8

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