We ask that both you and your nominee complete these forms online at:

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1 Dear Administrator/Executive Director: Following, you will find this year s HCANJ Foundation Nurse Scholarship application packet. We offer two awards of $2,000 each in both the LPN and RN categories. However, please be aware that the Foundation reserves the right to award either one or two scholarships in each category dependent on the number and caliber of nominations received. Please distribute this information to those eligible staff in your building who have been accepted into a nursing program. The forms included must either be typed or completed online. The link below will provide you with PDF documents that can be filled out online, saved, and printed out for mailing. We ask that both you and your nominee complete these forms online at: Your attention to our deadline of April 15 would be most appreciated as we cannot accept late or incomplete applications. If you have any questions, please don t hesitate to contact me by phone at (609) or at pattie@hcanj.org. Sincerely, Pattie Tucker

2 Dear Scholarship Applicant: Thank you for your interest in the Health Care Association of New Jersey Foundation s Nurse Scholarship Program. The purpose of this program is to assist qualified persons who wish to further their education toward becoming an RN or LPN in the long term health care profession. Applicants must: be a New Jersey resident; be accepted to an accredited LPN or RN program for the coming academic year; o A letter from the Director of the Professional Nursing Program, stating that you have matriculated into the Nursing Program, or are enrolled in pre-nursing and listing the semester you will begin the actual Nursing Program, must accompany the application. Please note that letters of acceptance, transcripts or grade progress reports will not fulfill this requirement. currently be employed in a member facility for at least 12 consecutive months, full or part time; o part time is defined as at least fifteen hours per week. The scholarship is open to facility employees only - family members of an employee are not eligible. be sponsored by a member facility with two letters of reference; o one from the facility administrator/executive director/owner; and o one from another professional or academic source. In addition, each of these references must fill out the included Recommendation Form. volunteer 25 hours per year in a member facility while in school if not employed by a member facility during that time; be willing to pledge that, upon successful completion of the nursing program, they will practice their nursing skills in a member long-term care facility for at least one year; and, complete the entire Application Form, which includes a brief statement regarding his/her interest and experience in long term care; include the above-mentioned letters of reference with completed Recommendation Forms (each in sealed envelope, per instructions on the Recommendation form); sign and include the Acknowledgement, Release and Financial Agreements, and have the facility Administrator sign the Certification of Eligibility. Please be aware of the requirement to complete the forms online and then print out for mailing. The easier it is for the judges to read your documents, the better it is for everyone. - over-

3 Letter to Applicant Nurse Scholarship Page Two All applications must be received in the HCANJ Executive Office on or before April 15. Incomplete or faxed applications cannot be accepted. PLEASE NOTE: INCOMPLETE OR FAXED APPLICATION PACKAGES WILL BE RETURNED TO THE FACILITY. Four scholarships can be awarded two for students studying to become a Licensed Practical Nurse and two to students studying to become a Registered Nurse. Each will allow tuition and/or courserelated expenses up to $2,000 per year, for a maximum of two years. Scholarship funds will be made payable to the student and school by the quarter or semester and continue only if school reports show the student to be successful in his/her efforts to achieve his/her RN/LPN degree. The Registrar of the school must verify eligibility; therefore, applicants should see the Registrar of their school about signing a release allowing us to obtain the appropriate information without delay. Again, we thank you for your interest and wish you much luck with your career. Health Care Association of New Jersey Foundation Please do not staple or bind any part of the application or supporting documentation. Thank you.

4 PLEASE COMPLETE THIS FORM ONLINE HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION RN/LPN SCHOLARSHIP APPLICATION Please check which scholarship you are applying for: RN LPN Applicant s Name Home Address Telephone Number Name of HCANJ Member Facility where you are employed Date employment began at facility Name of school you have been accepted to: Address of school Starting date Anticipated date of graduation Attach a letter from the Director of the Professional Nursing Program stating that you have matriculated into the Nursing Program, or that you are enrolled in pre-nursing, and listing the semester you will enter the actual Nursing Program. If required by the school of your choice, have you passed a minimum basic skills test in preparation for admission? Yes No Will it be necessary for you to take remedial courses prior to entering the Nursing Program? Yes No What special training related to long term care have you had? List special training you have had in other fields, if any.

5 RN/LPN Scholarship Application Form Page Two Please describe your future professional plans. Have you received any scholarship or tuition support from any other source(s)? If so, please specify the source(s). Do not include requests for financial aid. In the space provided, please describe the following: any experiences you have had in long term care, either personally or professionally; your interest in long term care as a profession; and what unique challenges you believe the long term care profession holds.

6 PLEASE COMPLETE ONLINE HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP ADMINISTRATOR RECOMMENDATION FORM (to accompany RN/LPN Scholarship Application) We appreciate your recommendation of the applicant. Please complete this form and place it in a sealed envelope along with the requested Letter of Reference. The applicant must return it with his/her application, which must be received in the HCANJ Executive Office on or before April 15. Name of Applicant Name of Administrator Name of Facility Address of Facility Phone Number of Facility How would you rate the applicant on the following: Low Average High No Opinion Maturity ( ) ( ) ( ) ( ) Sensitivity ( ) ( ) ( ) ( ) Commitment to nursing profession ( ) ( ) ( ) ( ) Ability to communicate ( ) ( ) ( ) ( ) Leadership ( ) ( ) ( ) ( ) On your organization letterhead, please provide a letter of reference that describes why you believe this applicant would be a worthy recipient of a HCANJ Foundation nursing scholarship and attach it to this form. Signature Date

7 PLEASE COMPLETE ONLINE HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP RECOMMENDATION FORM (to accompany RN/LPN Scholarship Application) We appreciate your recommendation of the applicant. Please complete this form and place it in a sealed envelope along with the requested Letter of Reference. The applicant must return it with his/her application, which must be received in the HCANJ Executive Office on or before April 15. Name of Applicant Name of Reference Address of Reference Phone Number of Reference Position of Reference In what capacity have you known the applicant? How would you rate the applicant on the following: Low Average High No Opinion Maturity ( ) ( ) ( ) ( ) Sensitivity ( ) ( ) ( ) ( ) Commitment to nursing profession ( ) ( ) ( ) ( ) Ability to communicate ( ) ( ) ( ) ( ) Leadership ( ) ( ) ( ) ( ) On your organization letterhead, please provide a letter of reference that describes why you believe this applicant would be a worthy recipient of a HCANJ Foundation nursing scholarship and attach it to this form. Signature Date

8 PLEASE COMPLETE ONLINE HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP CERTIFICATION OF ELIGIBILITY (to be completed by the facility administrator and accompany RN/LPN Scholarship Application) Member Facility Name Administrator/Executive Director/Owner Name Facility Address Facility Phone Applicant s Name Applicant s Position at facility Number of hours worked per week in facility Date of applicant s employment Has the applicant worked at your facility for at least 12 consecutive months? Certification The above named facility wishes to sponsor the indicated applicant for this year s HCANJ Foundation Nursing Scholarship Program. I have met with the applicant and am satisfied that he/she is eligible to apply for the scholarship. I will notify HCANJ immediately should the applicant become ineligible. If chosen to receive a scholarship, I will accompany the applicant to the HCANJ monthly business meeting at which scholarship recipients will be introduced to and honored by the association membership. Administrator Signature Date

9 ACKNOWLEDGEMENT, RELEASE, AND FINANCIAL AGREEMENT I hereby acknowledge that (facility) is sponsoring me as an applicant for a Health Care Association of New Jersey Foundation Scholarship. I have completed all the necessary forms and certify that the information I have given is factual. If I am selected as a Scholarship recipient, the Health Care Association of New Jersey has my permission to use the information on the application forms, any biographical data provided, and/or any photographs provided or taken, in their publications and other media. I understand that repayment of any monies granted to me by the Health Care Association of New Jersey Foundation s scholarship will be required should I, for some reason, not be able to complete the LPN/RN course, or should I not be able to work in a HCANJ member facility for the one-year service period after successfully completing the LPN/RN course. Check that all required forms are completed: Typed or printed application form Signature of Applicant Print Name Date Letter of matriculation from the Director of the Professional Nursing Program (Letters of acceptance, transcripts or grade reports will not fulfill this requirement) Letter of reference from Administrator Recommendation Form from Administrator Additional letter of reference Additional Recommendation Form Signed Acknowledgement, Release & Financial Agreement Signed Certification of Eligibility from Administrator Mail completed package to: HCANJ Attn: Pattie Tucker 4 AAA Drive, Suite 203 Hamilton, NJ