Yukon-Kuskokwim Health Corporation Physician Assistant and Health Care Professional Scholarship Application Form

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1 YKHC PHYSICIAN ASSISTANT AND HEALTH CARE PROFESSIONAL SCHOLARSHIP PROGRAM: The Yukon-Kuskokwim Health Corporation aggressively encourages the hiring of tribal health care professionals. This scholarship program is set up to encourage members of the 58 tribes served by YKHC and their descendents to pursue training as health care professionals where YKHC has a projected need. Our Physician Assistant and Health Care Professional Scholarship Committee will select scholarship recipients accepted or enrolled in accredited programs for education assistance to fund expenses such as tuition and fees, books, transportation and/or living expenses. Selected recipients will be required to commit to employment with YKHC upon completion of their program of study, or repay scholarship funds if they do not complete their training and licensure/certification. Tribal members must seek other funding opportunities before applying for funding by YKHC. HOW DO I APPLY?: To be considered for funding, submit the following materials to the YKHC Physician Assistant and Health Care Professional Scholarship Committee before the deadline. Please review the Application Guidelines for assistance in preparing your application. 1. Application. Complete, sign and date the YKHC Physician Assistant and Health Care Professional Application Form. 2. Proof of Eligibility as Tribal Member. Show membership in one of the 58 villages served by YKHC providing a copy of the Tribal Member Enrollment Card or Certificate of Indian Blood (CIB). 3. Proof of Eligibility as a Tribal Member Descendent. Provide a copy of (insert TPSS cards) your birth certificate to demonstrate your relationship as a Native lineal descendent of an enrolled member of one of YKHC s 58 villages as well as a copy of the enrolled member s Enrollment Card or Certificate of Indian Blood (CIB). Include a copy of an official document if your name has been legally changed from your name indicated in your birth certificate. 4. Letter of Acceptance. Submit a copy of an acceptance letter to an accredited program of study. 5. Grade Transcripts and/or Certificates of Completion. Submit a copy of your official grade transcripts and/or certificate/s of completion. a. If you have been out of school five (5) or more years, submit a resume outlining your learning experiences and work achievements during that period of time. 6. Statement of Purpose. Provide specific and detailed responses on a separate sheet of paper. a. New Applicants What are your education and career goals? Tell us about yourself and how your proposed program prepares you for a job at YKHC in one page or less. b. Repeat Applicants Update us on your education and career goals. To what extent are you moving toward your goals? What changes in plans might you be encountering and why in one page or less. 7. Letters of Recommendation. Provide at least two (2) letters of recommendation from a current or former teacher, employer or other person who knows of your past experience and potential to succeed in your chosen career. (No relatives please). Recommendation letters must be dated within six months of receipt of the application deadline date. Recommendation letters must include the applicant s name, the date, recommender s name, contact information and signature. Recommenders may use the Recommendation Form or submit a personal letter. 8. Budget Forecast. Submit the Budget Forecast Form showing your annual education budget in its entirety. Revised 4/03 Page 1 of 9

2 APPLICATION GUIDELINES: DEADLINES. The YKHC Physician Assistant and Health Care Professional Scholarship Committee must receive required application documents before the deadline to receive full consideration. Deadlines are as follows: June 30, September 30, December 1- Scholarship Requests Health Care Training (except MEDEX PA students) May 1, MEDEX Northwest Physician Assistant Training Scholarship for Summer DEFINITIONS. The following terms used throughout this scholarship application and guidelines document are defined for clarity. Academic Year- Begins August 1 and ends on July 31 (12 months). CIB- Bureau of Indian Affairs Certificate of Indian Blood. Descendents- Lineal descendants who are the children, grandchildren, or great-grandchild of an original enrollee to a tribe within the YKHC service area. GPA- Grade Point Average. Health Care Professions- YKHC focus career fields: o Occupations requiring Licensure- Any health care occupation requiring State of Alaska licensure, where YKHC has a projected employment need, i.e. audiologist, dental hygienist, dentist, dietician, nutritionist, midwife, certified nurse aide, licensed practical nurse, registered nurse, advanced nurse practitioner, optician, optometrist, paramedic, pharmacist, pharmacy technician, physical therapist, physician, psychologist, professional counselor, marital and family therapist, social worker. o Occupations requiring Certification- certified health care occupations, where YKHC has a projected need, i.e., chemical dependency counselor, medical technologist, respiratory therapist, ultrasonographer, x-ray technician. o Allied Health Care Occupations- allied health care occupations, where YKHC has a projected need, i.e., civil engineer, health records administrator, health educator, injury prevention specialist, safety officer, sanitarian. Full-Time Student- Taking at least 12 undergraduate credit hours or at least 9 graduate credit hours during a semester/term/quarter. DISBURSEMENT OF FUNDS. For tuition, books, fees and university/school sponsored room and meal plans, YKHC will disburse award checks directly to the university/school s financial aid office. A copy of the disbursement letter sent with any check to the university/school will also be sent to the student. Any annual scholarship awards will be disbursed in two equal installments based on a two-semester academic year. Disbursement of the second installment will be subject to review of the student s official grade report for the semester/term/quarter just completed. For awards that include transportation, non-university/school sponsored room and meals, and other expenses, YKHC will make individual arrangements in writing with the funded student. 1. ELIGIBILITY. Individuals who may apply for the YKHC Physician Assistant and Health Care Professional Program are: members or descendents of any 58 recognized tribes in the YKHC service area who are 16 years or older, applicants accepted into an accredited program of study for a licensed health care occupation for which YKHC has a projected employment need, or full-time students. Revised 4/03 Page 2 of 9

3 GRADE POINT AVERAGE (GPA). To qualify for this scholarship and continued support, scholarship applicants enrolled in the MEDEX Northwest Physician Assistant Training Program must maintain a minimum cumulative GPA of 3.0. Students in other programs of study must maintain a minimum cumulative GPA of the greater of 2.0 or the minimum GPA established by academic program being funded. GRADE TRANSCRIPTS. Submit an original or a copy of the original official grade transcripts with application. PROOF OF COMPLETION. Submit a copy of official grade transcripts upon completion of each funded semester/term. No newly approved or additional installments of previously approved scholarships will be released until grade transcripts are reviewed by YKHC. Upon graduation or completion of study an updated resume must be submitted for consideration of employment opportunities at YKHC. REQUEST FOR APPLICATION FORMS. It is a student s responsibility to request and obtain the necessary application materials and submit the completed materials by announced deadlines. SELECTION CRITERIA. Selection of scholarship recipients will based on several criteria, such as: timely submission and completeness of application, scholastic achievement, rigor of course work or degree program, quality of the statement of purpose, student financial contribution, financial need, grade level, previous work performance, education and community activities, recommendations by teachers, employers and others who know of the applicant s past experiences and potential to succeed in a chosen career, seriousness of purpose, practicality of education and professional goals. Priority consideration will be given to students as follows: 1st PRIORITY: applicants enrolled in the MEDEX Northwest Physician Assistant Training Program with a minimum cumulative GPA of nd PRIORITY: applicants enrolled in accredited programs of study leading to an Alaska license in a health care occupation with a minimum cumulative GPA of 2.0. (and/or meet minimum standards) SELECTION DECISIONS. The YKHC Physician Assistant and Health Care Professional Scholarship Committee makes award selections and their decision is final. Applicants will be mailed results of their applications. Applicants in other areas may apply, but the decision is made by the YKHC President/CEO. Revised 4/03 Page 3 of 9

4 APPLICANT INFORMATION: please type or print legibly. Full Name: Permanent Mailing Address: Mailing Address at School: address: Social Security Number: Daytime Phone No.: Phone No. at School: Fax. No. at School Date of Birth: I am an enrolled member of one of the 58 tribes served by YKHC: Yes No Name of Enrolled Tribal Member Tribe and Enrollment Number: If Descendent, I am the Tribal Member s Child Grandchild Great-grandchild (Attach copies of Birth Certificate & Member s CIB or Enrollment Card); Tribal Member s Name: Proposed Program of Study (Major/Minor): Proposed Health Care Occupation: I will be enrolled as a fresh. soph. jr. sr. 1 st year graduate 2 nd year graduate other Expected Enrollment Date (Month/Year): Expected Graduation Date (Month/Year: My School s Calendar is based on: Semesters Quarters Other: Expected # credits for term(s) for which this scholarship applies: My current cumulative GPA is: I have been accepted to this Accredited University/College: Financial Aid Office Mailing Address: Phone: Fax: I have requested at least two letters of recommendation to be sent to YKHC. YES NO. I am at least 16 years of age: YES NO I have requested that my official grade transcript/s or certificate/s of completion for my most recently completed semester/term/session be sent to YKHC as soon as they are available. YES NO, but I will do so immediately. I have applied for funding from the following funding sources (be specific): I have been convicted of a Felony: YES NO. If yes, explain: Contact information of person through whom I can always be located: Name: Relationship: Permanent Mailing Address: Daytime Phone No.: Revised 4/03 Page 4 of 9

5 EDUCATION AND EMPLOYMENT EXPERIENCE: Please attach your resume if appropriate. High School Diploma* Date**: GED* Date**: Certificates Earned* Associates Degree* Undergraduate Degree* Graduate Degree* *Please provide copies of transcripts and certificates and/or degrees earned. Date of Completion**: Date of Completion**: Date of Completion**: Date of Completion**: REQUIRED APPLICATION DOCUMENTS: Please complete and submit these documents. Please keep copies for your records. DOCUMENT: 1. This Application, completed, signed and dated. (9 pages total) YES 2. Tribal Enrollment Card or CIB (Certificate of Indian Blood). YES 3. Birth Certificate(s) showing Descent (if a descendent) YES Official document showing Name Change (if appropriate) YES 4. Proof of acceptance or enrollment to accredited program of study. YES 5. Copies of Official Grade Transcripts (high school and any college) YES Copies of Certificate(s) of Completion (if appropriate) YES 6. A Written Statement of Purpose. YES 7. At least two Recommendation Forms or Letters of Recommendation. YES 8. Budget Forecast. YES Deliver or Mail documents to: YKHC PA Scholarship Committee Attn: YKHC Learning Center Director P. O. Box 528, Bethel, AK For More Information: Voice: or ext Fax: SUBMITTED: Revised 4/03 Page 5 of 9

6 STATEMENT OF CORRECTNESS, UNDERSTANDING AND AUTHORIZATION: PLEASE READ CAREFULLY BEFORE SIGNING: 1. Application Information. To the best of my knowledge and belief, I attest that the information contained in this application is true, correct and complete. I understand that this application does not commit YKHC to award an education scholarship or pay any costs I incurred to submit this application. I also understand that the action taken by the YKHC Physician Assistant and Health Care Professional Scholarship Committee is final. 2. Use of funds. I understand and agree that any scholarship funds awarded will be used solely to further my education in the approved program. 3. Unused award. I understand and agree that the full amount or any portion thereof will be repaid to YKHC if, for any reason, I am unable to use an award. 4. Applicant Obligations. If awarded a scholarship, I agree to: a. Maintain full-time enrollment until completion of the course of study for which the scholarship is provided; AND b. Maintain an acceptable level of academic standing (i.e. minimum GPA of 3.0 for MEDEX students and the greater of 2.0 or the minimum GPA established by funded program); AND c. Work for YKHC as a full-time practitioner of the profession for which the education scholarship is awarded upon completion of the necessary licensure on a two-year-for-one-year basis with a minimum of two years of employment. 5. Defaulting on the Scholarship Obligation. If awarded a scholarship, I agree that if I: a. Voluntarily terminate academic training before graduation from the funded education program, or if I am dismissed from school for academic or disciplinary reasons, I will be liable to YKHC for repayment of scholarship funds paid to me and to my school on my behalf. I agree to repay YKHC within 3 years from the date academic training is terminated. YKHC agrees not charge interest on any part of this indebtedness during this three-year period. b. Fail to begin or complete the service obligation for any reason other than failing to complete academic training, I will be liable to repay YKHC all scholarship funds paid to me or my school on my behalf, plus interest, within three years of when I failed to begin or complete my obligation period. c. Default on any scholarship debt to YKHC, my delinquency will be referred for debt collection and/or litigation and may be subject to charges for administrative and court costs of collection. 6. Certificate of Completion or Grade Reports. I understand that immediately upon completion of the semester/term, I must submit a copy of my official grade report, certificate/s of completion to YKHC to verify completion of the courses of study for the funded semester/term within 60 days. 7. Submission of Application. I understand that it is my responsibility- not YKHC s - to obtain necessary application materials from YKHC and submit the completed application so that it is received by YKHC before the deadline to receive full consideration for a scholarship award. 8. Release of Information. I consent to the release of information to Yukon-Kuskokwim Health Corporation from my educational institution regarding my progress as a student. This information may include, but is not limited to my major, grades and GPA, degree/certification received. I understand that this release of information is a condition for receipt of scholarship funds. My University/College: Mailing Address: Phone: Fax: I give YKHC permission to release my name and information about my program of study for reporting and promotional efforts, i.e. for articles, brochures, posters, etc. I have read and understand the above Statement of Correctness, Understanding and Authorization and agree to abide by the terms and conditions of the award, if approved. SIGNATURE OF APPLICANT DATE Revised 4/03 Page 6 of 9

7 RECOMMENDATION FORM: Please print or type. Name of Applicant: Date: Proposed Program of Study (Major/Minor): Proposed Health Care Occupation: Reference s Name: Daytime Phone No.: Mailing Address: Fax No.: address: Relationship to Applicant: I have known the applicant for years In the space below, or in a personal letter, please provide a Recommendation Letter to support the student s application for funding by the YKHC Physician Assistant and Health Care Professional Scholarship Program. DELIVER OR MAIL TO: YKHC PA Scholarship Committee, YKHC Learning Center Director, P. O. Box 528, Bethel, AK If you have any questions, please call or extension Revised 4/03 Page 7 of 9

8 RECOMMENDATION FORM: Please print or type. Yukon-Kuskokwim Health Corporation Name of Applicant: Date: Proposed Program of Study (Major/Minor): Proposed Health Care Occupation: Reference s Name: Daytime Phone No.: Mailing Address: Fax No.: address: Relationship to Applicant: I have known the applicant for years In the space below, or in a personal letter, please provide a Recommendation Letter to support the student s application for funding by the YKHC Physician Assistant and Health Care Professional Scholarship Program. DELIVER OR MAIL TO: YKHC PA Scholarship Committee, YKHC Learning Center Director, P. O. Box 528, Bethel, AK If you have any questions, please call or extension Revised 4/03 Page 8 of 9

9 BUDGET FORECAST FORM: PLEASE NOTE: Applicants must show that efforts were made to obtain other sources of funding. Name: Program of Study: Expected Enrollment Date (Month/Year): Expected Graduation Date (Month/Year): My Program s Calendar is based on: Semesters Quarters Other: College/University of Enrollment: Annual Budget Forecast: EXPENSES AMOUNT SOURCES OF FUNDS AMOUNT Direct Academic Costs Tuition Fees Books & Required Supplies Room and Meal Costs* Room Meals Transportation * Other: TOTAL ANNUAL EXPENSES $ $ $ $ Personal Resources for Schooling Student Contribution/Savings Family Contribution Insert ( other) Government Allowances Veterans Administration Aid State/Federal Social Security Insert ( other) $ Academic Financial Aid I.H.S. Scholarship BIA Scholarship Scholarships/Fellowships Alaska Student Loan Pell Grant Insert ( other) $ TOTAL SOURCES OF FUNDS Amount Needed to Balance Budget (Total Expenses MINUS Total Sources) Your Request to the YKHC PA Scholarship Program $ YKHC Annual Funding Request by Academic Year: Fall 2003 Spring 2004 Fall 2004 Spring 2005 Fall 2005 Spring 2006 Fall 2006 Spring 2007 TOTAL REQUEST $ $ $ $ $ * Only applies to students who must live away from his/her permanent home in order to attend school. Revised 4/03 Page 9 of 9

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