Become a Certified Nursing Assistant and Make a Difference in the Lives of Others! Applicant Name: Home Address: City: Zip Code:

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1 Caring fr Our Elderly Prject 2014 Schlarship Applicatin SAU TECH Nursing Assistant Training Prgram Funded by Blue &Yu Fundatin fr a Healthier Arkansas Becme a Certified Nursing Assistant and Make a Difference in the Lives f Others! PLEASE PRINT LEGIBLY Applicant Name: Hme Address: City: Zip Cde: Cunty: Primary Phne: Cntact Phne: Highest Grade Cmpleted: Have yu had any caregiving experience? (Circle) YES NO If yu answered yes t the abve questin please briefly describe belw: (May attach additinal sheets if needed) If yu are awarded this schlarship, briefly explain what yu intend t d with a CNA certificatin:

2 Caring fr Our Elderly Prject 2014 Schlarship Applicatin SAU TECH Nursing Assistant Training Prgram Funded by Blue &Yu Fundatin fr a Healthier Arkansas D yu have any ther surce f funding fr this prgram? (Circle) YES r NO Current Emplyment: Annual Husehld Incme: By signing belw I understand I am respnsible fr the cst f cmpleting a TB skin test befre attending the clinical prtin f the class. Applicant Signature/Date *ADDITIONAL REQUIREMENTS 2 Letters f Character Reference with cntact address and phne number Applicants will be ntified at least ne week prir t start f class. Upcming Class Dates TBA in January, February, March, April, July, August, September, Octber, Nvember Please mail cmpleted applicatin t address belw r in persn t Business Building ffice 120. SAU TECH Allied Health Department/CFOE P.O. Bx 3499 Camden, AR 71711

3 ~"C'Hr,w.ai1ii YOU first! SOUTHERN ARKANSAS UNIVERSITY TECH Nursing Assistant Training Prgram NAME: Sc. Sec. #:. ADDRESS: Telephne #: CITY: STATE ZIP COUNTY Date f Birth: Place f Birth (City, State): Marital Status: Married: ---- Single: Separated: Divrced: ---- Are yu a citizen f the United States? Yes ---- N ---- Name and Address f High Schl Attended: Year Graduated: If yu did nt graduate, have yu cmpleted GED: Yes --- N --- Previus Wrk Experience (List mst recent first): Emplyer City Jb TitlelDuties Frm T In Case f Emergency, Cntact: Name: Phne: CAREER PLANS Why d yu want t take this curse? What d yu plan t d when yu finish this curse? ( ) Lk fr a Jb ( ) Cntinue Educatin What type jb d yu want? Hwilid~u~ara~~thiscla~? Signature Date

4 ~TEC II~ ~VOUfirHIf SOUTHERN ARKANSAS UNIVERSITY TECH Nursing Assistant Training Prgram Health Assessment Frm NAME: Date: Address: Phne: Age:, Height: Weight: PAST HISTORY --Please give as cmpletely as pssible. A. Acute Illnesses=-Ouratin and Year f Hspitalizatin B. Lng-Term.Ilnesses-c-Duratin and Year f Hspitalizatin C. Any Histry f Back Truble? If YES, Please describe: D. Any Histry f Seizure and Treatment? If YES, Please describe: E. Date f Last Menstrual Perid: Is yur menstrual perid: Regular Prlnged Excessive Painful *Ifyu are pregnant, a release frm yur dctr is required prir t entering the prgram* F. Are yu currently taking any type f medicatin? If YES, What kind?: G. Have yu been treated r are yu currently being treated fr a mental r emtinal cnditin? liyes,pka~d~cribe:, H. Are yu in suitable Physical and Emtinal cnditin fr training as a Nursing Assistant? 1. In case f emergency, cntact: Name: Phne: Signature Date

5 PLEASE PRINT ALL INFORMATION LEGIBLY Fall " Spring Summer I Summer II.. Year Student's Full Legal Name First Middle. Last Scial Security Number: ~ " Please check nly ne bx as the"primary reasn yu are attending SAU Tech this term: D" "0 0" (01) T cmplete cursewrk tward a SAD Tech assciate's degree, certificate "prgram, advanced certificate prgram, r certificatef prficiency (A.A., A.S., A.A.s., Adv.Crt.Cert.) (02) T cmplete cursewrk t transfer t anther institutin in"rder t receive. their degree r certificate f cmpletin. (03) T btain r imprve jb skills. (04) T acquire r maintain licensure (05) T imprve selfi'persnal enrichment (nn-jb-related skills) (06) T cmplete cursewrk fr cncurrent high schl credit and cllege credit.(07) T"explre educatinal pprtunities available t me at SAU Tech (08)" Other (Please Specify): """ MUST BE STAPLED TO REGISTRATION" C~)PY-TlIAT IS SUBMITTED" TO REGISTRAR

6 Nursing Assistant Schlarship Criteria: Cmpleted Schlarship Applicatin. Cmplete Applicatin Enrllment Packet fr SAU Tech Have 2 letters f character reference Persnal statement which tells why the applicant shuld be awarded this schlarship and future career gals/bjectives Prf f Financial Need/Assistance Selectin Prcess: The selectin prcess will be based upn the written applicatin, persnal/prfessinal references and interview. The Schlarship Selectin Cmmittee will review all cmpleted schlarship packets and make recmmendatin fr selectin. A persnal interview with an Allied Health representative may be scheduled. Only cmpleted applicatins alng with required criteria received by the deadline date will be cnsidered. ( 1 week prir t class start date and after January class 2 weeks prir t class start date) Schlarship Agreement: The SAU Tech will ntify schlarship recipients f award. Upn curse cmpletin, the schlarship recipient must agree t actively seek emplyment in rder t cver the cst f the state testing exam. Shuld the schlarship recipient fail t pass the required licensing exam at the first pprtunity, he/she may retake the certificatin exam at the expense f the recipient. Once awarded schlarship, the student must cmplete the entirety f the curse and abide by plicies, which include but nt limited t in academic, attendance, cnduct, and clinical. Return Applicatin t SAU Tech Please mail the applicatin t the address belw r return in persn t Business Building rm 120. Please make sure yu have all items n Schlarship Criteria t turn in. SAU Tech Allied Health Department P.O. Bx 3499 Camden, AR 71711