The Nursing Leadership Council will review the goals of the education fund yearly or as necessary.

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1 Nurse Education Maricopa Health Foundation Perpetual Nurse e Education Perpetual Scholarship Fund Scholarship Fund The Maricopa Health Foundation Nurse Education Perpetual Scholarship Fund (NEP) is intended to assist those that are actively pursuing advanced degrees in nursing and obtaining their certification in nursing specialties. The recipients understand that the NEP Scholarship is funded by donors who are committed to assisting nurses who are committed to advancing their education. The Fund is intended to be a perpetual education fund where anyone that receives the scholarships helps preserves the fund by giving back a financial donation to the fund. The scholarships are awarded on a semi-annual basis or per-semester and will be dependent on meeting continuing eligibility criteria. Awards may be used for tuition, books, and reimbursement of certification exams. Applicants are limited to one scholarship per 12 calendar month period. There is a maximum award of $2,750 or 80% of tuition, books or certification per 12 calendar month period. Students working toward a degree will receive their disbursements and will need to provide a copy of class schedules. The Nursing Leadership Council will review the goals of the education fund yearly or as necessary. Scholarships Available: RN's and LPN s that are pursuing their BSN. MS degree in a nursing related field One scholarship is available annually Ph.D./DNP degree in nursing One scholarship is available annually Certification in area of specialty Selection Criteria The selection of the scholarship recipient is based on completion of the application, meeting eligibility criteria, references, and a personal interview. Additional Information For additional information, contact Nursing Leadership Council Chair: Application Process I. Download application form from the Maricopa Health Foundation website. II. If you are submitting for reimbursement of a certification exam submit completion of the certification along with a receipt. III. IV. Include two recommendations from peers who have knowledge of your qualifications. Completed application (incomplete applications will not be processed) must be submitted by June 1 st and Nov. 1 st and mailed to: Maricopa Health Foundation Nurse Education Fund c/o Nursing Leadership Council Attention: Chair Our Address

2 Nurse Education Perpetual Scholarship Fund Maricopa Health Foundation Nurse Education Perpetual Scholarship Fund Program Application Application: Name Previous Name(s) Address City, State, Zip Home Phone_( ) Cell phone ( ) Date of Birth SS# I am currently Full time Part-time Full-time Unit based pool Full time IRP Employee ID: Job Title: Degree: RN License number: LPN License number: Department: Cost center: Date of hire: Work phone number: Section I: Eligibility Criteria 1. MIHS RNs and LPNs who are employed full-time and part-time at.5 FTE or greater 2. Full-time MIHS IRP and UBP employees with greater than 5 years employment 3. Be an employee In good standing (no written discipline for one year prior to initial application and for duration of program) 4. The nurse s license must be in good standing with they Arizona Board of Nursing 5. Employed at MIHS for at least 6 months 6. Accepted in an a. accredited BSN program b. accredited MSN program c. accredited DNP/Ph.D. program in nursing 7. Completed Certification in your area of specialty, if you are applying for certification reimbursement.

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4 Section II: Educational Background and Plans How will this scholarship help you? Earn a degree. If yes, list institution, course of study and degree working toward and expected graduation date. Institution Course of Study Degree: Graduation Date Receive certification. If yes, list type of certification, certifying agency, date of test and whether this is for an initial or renewal certification. Attach copy of completed certification application. Type of Certification Certifying Agency Test Date Initial Certification or Certification Renewal List of schools attended, starting with the most recent up and including high school. Schools City/State Dates diploma/degree Section III. Management comments on job relatedness & eligibility requirements Employee meets eligibility criteria to the best of your knowledge and has completed initial MIHS probation. initials Manager s name printed: phone: Manager s Signature: Date: Section IV: Please list current participation in MHIS committees, community involvement, Leadership opportunities, or projects that you have completed for MIHS. ( Utilize additional paper if needed)

5 Section V: Written Statement (required by all applicants) please attach a maximum one-page type-written statement that includes information you believe the Nursing Leadership Council should know as they consider your scholarship application. Share how you and MIHS would benefit from this scholarship. You may include academic achievements, leadership skills, community and school participation and financial obligations. YOUR FUTURE EDUCATIONAL GOALS MUST BE INCLUDED. This statement is a key part of your scholarship application. Be concise.

6 Section VI: Certification and Agreement By signing this application form, I attest that the information provide on this application is true and accurate. I hereby authorize the Maricopa Nursing Leadership Council to review all information in order that they may determine my eligibility for this award. If awarded a scholarship, recipient will write the Foundation Board of Directors, and may be asked to participate in scholarship functions or award ceremonies. By accepting a scholarship, the recipient understands that the award is not automatically renewed. Please check all boxes that apply: I understand the Maricopa health foundation my use my name in conjunction with this program in printed materials and the web. I understand, if awarded a scholarship that I will write a personal thank you letter to the donor and Foundation Board of Directors. (All recipients) I understand that I may be asked to participate in any scholarship functions and/or award ceremonies as requested. (All recipients) I understand that I am required to maintain a 2.5 cumulative grade point average on a 4.0 scale. I am required to submit verification of acceptance in an accredited school of nursing Remain an employee in good standing (no written discipline for one year prior to initial application and for duration of program). I am required to complete the academic program within three years of commencement. I understand that Part-time scholarship amounts will be a percent equivalent of the fulltime scholarship amount. I understand the scholarship will be distributed on a semi-annual basis or per-semester and will be dependent on meeting continuing eligibility requirements I understand the disbursement of funds will be funded when the need is demonstrated. Print Applicant Name Signature Date

7 This will be a separate page not part of the application ************************************************************************************************************************** For Office Use Only Date received: Criteria Verified Initials Date Accepted in an accredited nursing program? Employee in good standing? License is active and good standing with the AZ board of Nursing? Has passed probation? Has turned in completed certification exam receipt if applicable? If Full-time IRP ( non-benefited) IRP and UBP employees do they have greater than 5 years of employment? Employee is full- time or.5 Part time When Scholarship dollars are limited and the numbers of applications far outnumber the available scholarship assistance, it is necessary to utilize a rating system for applicants. Please assign a numerical rating from 1-5 being as objective as possible. Score Low High Current participation in Community, leadership activities committees, etc Written essay: how MIHS will benefit? How will the community benefit? The applicant has revealed high financial obligations? Total Score: Total all scores from the interviewers and divide by the number of interviewers a Ranking will be noted: Ranking: Has person been contacted for an interview? Yes No comments: Date and time of interview: Comments: