State of Nevada s Western Interstate Commission for Higher Education (WICHE) Health Care Access Program (HCAP)

State of Nevada s Western Interstate Commission for Higher Education (WICHE) Health Care Access Program (HCAP) The State of Nevada is concerned over the growing number of medically underserved populations. Medically underserved are those individuals or areas in the state that struggle or are unable to receive adequate health care services. Therefore, to assist in meeting the state s health care needs, Nevada WICHE has support in the following: MENTAL HEALTH NURSE INCENTIVE PROGRAMS Annual Support Amounts (Amounts are approximate and subject to change) APPLICATION DEADLINE: October 1 st OF CURRENT ENROLLMENT YEAR NURSING: PSYCHIATRIC / MENTAL HEALTH 2015-2016 2016-2017 Maximum Funding Duration Mental Health Coursework (2 classes) $2,400 ----------- 1 Year PROGRAMS REQUIREMENTS: A. The above amounts are PAID DIRECTLY TO THE INSTITUTION on your behalf and enable you to acquire your education at a reduced rate. You will still be responsible for the balance of any tuition and/or fees as determined by the institution. B. You must reside in Nevada and practice in your professional field in a medically underserved region or with a medically underserved population for one year. (Contact the office for further clarification, if needed.) Defaulting on the program s requirements may result in a penalty of triple principle plus interest of funds. C. You must repay 10% of the total financial support amount within 5 years after you graduate. Monthly loan payments commence one year after graduation or termination of studies. D. You will be asked to obtain a co-signor s signature for the promissory notes. A parent, guardian, or other responsible party can be a guarantee/co-signor; however, spouses are not accepted. E. The funds are competitive based upon acceptance by an educational program, number of applicants, availability of state funds, and/or an interview with WICHE. F. Application Deadline: October 1 st of the current enrollment year. Late applications will be accepted and placed under alternate status. If you are interested in further information, contact Jeannine Warner State of Nevada WICHE j.warner@gov.nv.gov (775) 687-0991

WICHE NEVADA Western Interstate Commission for Higher Education Health Care Access Program (HCAP) for Psychiatric/Mental Health Nursing INSTRUCTIONS FOR APPLICATION 1. Complete all sections of the application form. Read the application carefully and answer all questions precisely. Do not forget to sign sections VI & VII. Print using black ink or type and mail to the address below. 2. Sign the Consent and Waiver form (page 5) and the Waiver (page 6). 3. Sign the attached Loan Disclosure form. (If form not attached, contact us at the number below.) 4. Include a copy of your letter of acceptance from the institution in which you will be enrolled to the Nevada WICHE office when received. Awards will not be made without this letter. 5. Proper postage must be applied or your application will be returned. 6. NOTE: Funding for WICHE support is contingent upon annual appropriation by the State of Nevada and available funding. Annual Deadline Date: October 1st Applications must be received in our office by this date. Applications received after this date will be accepted as alternate status for funding. Mail application documents to: Nevada Western Interstate Commission for Higher Education (WICHE) 100 N. Stewart St., Suite 220 Carson City, NV 89701 Phone:(775) 687-0991 / Fax: (775) 687-0990

State of Nevada Western Interstate Commission for Higher Education (WICHE) Type or print in ink. Final in-office receipt for all applications: October 1 st. I. PERSONAL INFORMATION ( ) Last Name First Middle (Full) Maiden Social Security No. Birth Date Birthplace Gender: Female Male () How did you hear about WICHE? CURRENT ADDRESS: (All mail will be sent to this address) school holidays summer year-round Street / P.O. Box Apt. # City State Zip Primary Phone ( ) Alternate Phone ( ) E-mail PERMANENT ADDRESS - P.O. BOXES NOT ACCEPTED: Street Apt. # City State Zip Spouse s name and address Father s name and address Mother s name and address II. EMPLOYMENT (if applicable) Employer s name Address: P.O. Box/Street Suite # City State Zip Job Title: Phone ( ) Length of employment yrs. mos. III. RESIDENCY Are you a United States citizen? Yes No If you are not a United States citizen, attach a copy of your Permanent Resident Card. Are you a Nevada resident? Yes No Driver s license #: Date issued State of license I have been a legal resident of County since: month day year If you have not been a resident of the state of Nevada for one (1) year prior to applying for Nevada WICHE certification but believe there are factors to be considered which may make you eligible as a Nevada resident, please explain fully in an attachment to this application. Page 2

IV. EDUCATION HISTORY Most recent colleges and universities attended (including community/junior colleges). List all institutions attended. Attach additional sheet if more space is needed. 1. from: to: 2. from: to: 3. from: to: V. CHECK PROGRAM OF CHOICE FOR PROFESSIONAL TRAINING: Psychiatric nursing coursework - 2 classes: Advanced Health Assessment Advanced Pharmacology WHEN DO YOU PLAN TO APPLY FOR ADMISSION TO SCHOOL: APPROXIMATE DATE OF ENTRANCE: ANTICIPATED ENDING/GRADUATION DATE: Month Year Month Year Month Year VI. CERTIFICATION I certify that all statements and data provided in this application are true and correct to the best of my knowledge. I understand that if any information is found to have been falsified at any time during my participation in the WICHE program, I may be denied receipt of any program support and, if support has been received, immediately dismissed from the program and repayment terms will become effective. I further understand that funding for WICHE support is contingent upon annual appropriation by the State of Nevada, and funding is not released until its availability. Signature of Applicant Date VII. STATEMENT OF INTENT TO PROVIDE SERVICE I affirm my intent to practice in the state of Nevada upon completion of my education and/or internship/residency. I understand I must fulfill the service requirements of this loan or face default penalties. (Additional requirements are included in Nevada Revised Statute 397 and Nevada Administrative Code 397, and the rules and regulations of the WICHE Commission.) Signature of Applicant Date If you would like additional information on Chapter 397 of the Nevada Revised Statutes and any revisions thereof, please contact the state of Nevada WICHE office at the address/phone number listed below or visit the State of Nevada Legislative website @ www.leg.state.nv.us. Mail completed applications and all supporting documentation to: WICHE 100 N. Stewart St., Suite 220 Carson City, NV 89701 (775) 687-0991 Did you keep a copy of the application and supporting documents for your files? Did you sign and date the Certification and Statement of Intent to Provide Service Sections above? Did you sign and date the Consent and Waiver and Loan Disclosure forms? Remember to submit a copy of your letter of acceptance from the program in which you will be enrolled. Page 3

PLEASE COMLETE THE FOLLOWING QUESTIONS. Use additional sheets, if needed, and attached to application. 1) List your current and prior work experiences (paid and/or volunteer) that are relevant to the mental health nursing field. Describe the types of settings in which you currently work, including the communities or geographic areas, the fields/professions of persons with whom you work, and the type of people you serve. Describe the settings in which you would like to work if different than your current location. 2) Explain the factors that attracted you to your chosen career path. Are there other professional areas of interest to you that you are looking to pursue? Page 4

CONSENT TO TRANSFER STUDENT RECORDS THROUGH NEVADA WICHE S HEALTH CARE ACCESS PROGRAM (HCAP) WESTERN INTERSTATE COMMISSION FOR HIGHER EDUCATION DESCRIPTION OF USE OF PERSONAL RECORDS: The Nevada Western Interstate Commission for Higher Education (WICHE) collects and uses information concerning student eligibility for its Health Care Access Program ( Program ); admission; enrollment; academic progress; graduation and/or termination from the professional Program; and payment of fees by the state through WICHE to the receiving school. This information is exchanged between and among the staff and commissioners of Nevada WICHE office; the professional school(s) to which the student makes application and is admitted; and, State of Nevada agencies collaborating with the Program. The WICHE Commissioners will review applications to consider eligibility of student(s). Periodic accounting for its student programs in the state and in the region may result in publication of reports which may contain the student s name, home address, year of enrollment, enrolling institution, and money spent by the state to support the student s effort to reach an education objective. NOTIFICATION CONCERNING STUDENT ACCESS TO PERSONAL RECORDS: Any student participant or applicant for participation in the Program has access to his/her personal records maintained as a part of the exchange activity. He/she may inspect and/or receive copies at a cost not to exceed the actual cost of reproduction. CONSENT AND WAIVER I understand that it is necessary to process student records in order to carry out the purpose of the Program, providing access to educational opportunities for Nevada residents. I understand that the record-keeping process requires preparation, transmission, receipt, filing, and reporting of information appropriate to the effectiveness and continuity of the Program. I hereby consent to the transfer of personally identifiable educational records between and among the participants of the Program of the Nevada Western Interstate Commission for Higher Education to include the following: Information concerning student eligibility, acceptance, and educational attainment. Information concerning fees paid by the Nevada WICHE office to the receiving school. I hereby waive my right to receive specific notification of the transfer of such records. I understand that personally identifiable educational records will be used only to the extent necessary to carry out the purposes of the Program including reasonable research studies necessary to evaluate and improve the Program. Any general research report of information that might prove harmful or embarrassing will be included only when anonymity is preserved. Use of the information will be permitted only when, in the judgment of the Program Director or other designated staff member, the request for information is wholly consistent with my best interest and the purpose of the Program. I understand that a log will be maintained to identify access to my records, which is permitted pursuant to law, and this information will be available to me upon appropriate request. A locked file will be maintained for the regular storage and protection of personal educational records. Lists of applicants certified as eligible for support Admissions reports, withdrawal reports, and annual reports for WICHE students. Special letters of inquiry and response as required to address questions and concerns identified by Program participants. I understand that the information referred to herein will be available only to WICHE staff and commissioners, designated institutional officials, and state officials and collaborators as required to carry out their official duties. I further consent to the transfer of all or a portion of the above educational records to admissions offices and WICHE staff as required to accommodate the needs of the Program provided that the officers receiving the information will not permit any other party to have access to such information without the express written consent of the undersigned. Name (Please print) Signature Social Security Number Permanent Address (Street) (City) (State) (Zip) Date Page 5 REV: 4/2015

Nevada Governor s Office of the Western Regional Education Compact Western Interstate Commission for Higher Education 100 North Stewart Street, Suite 220 Carson City, NV 89701 Phone 775-687-0991 Fax 775-687-0990 Commissioners Vance K. Farrow Frederick B. Lokken Vic Redding Jeannine M. Warner Director Certifying Officer WAIVER Western Interstate Commission for Higher Education (W.I.C.H.E.) Open Meeting Law NRS 241 states that a public body shall provide individual notice to persons against whom the public body may take certain administrative action and must give written notice to that person of the time and place of the meeting. Such written notice must either be (a) delivered personally to that person at least five (5) working days before the meeting, or (b) sent by certified mail to the last known address of that person at least twentyone (21) working days before the meeting. However, if the Nevada Western Interstate Commission for Higher Education (WICHE) Commission has to serve you with this written notice, it may have the effect of delaying consideration of your application. By signing this waiver form, you hereby acknowledge your right to be noticed under NRS 241; however, you hereby waive such notice so that Nevada WICHE may discuss and consider your application at a future publicly noticed meeting. An agenda of meetings is provided at the Nevada WICHE website at www.nevadawiche.org. Should you require formal notification of the meeting via certified mail, please contact the Nevada WICHE office at the address above. Date Signature of Applicant/Student Print name of Applicant/Student NRS 241.034 Providing individual notice to persons against whom the public body may take certain administrative action or from whom the public body may acquire real property by the exercise of the power of eminent domain.: Written notice to person required; copy of record. A public body may not hold a meeting to take administrative actions against a person or to acquire real property by condemnation from a person unless the public body has given written notice to that person. The written notice must be either: (1) Delivered personally to that person at least 5 working days before the meeting; or (2) Sent by certified mail to the last know address of that person at least 21 working days before the meeting. A public body must receive proof of service of the notice required by this subsection before the public body may consider the matter. Proof of receipt of the notice is not required.

Page 6 LOAN DISCLOSURE STATEMENT NEVADA WICHE HEALTH CARE ACCESS PROGRAM (HCAP) This document provides an outline of the terms and conditions of the Nursing-Psychiatric Competencies HCAP financial obligation for a one-year funding period. The support fee and interest amounts are estimates only. Amounts may differ depending upon the actual approved support fee, term of loan, and additional accrued interest or fees. Your signature acknowledges that you understand the payback obligation to WICHE and the State of Nevada. IF YOU DO PRACTICE IN NEVADA AS REQUIRED, YOU WILL OWE: Student Loan: 10% of support fee paid to school on your behalf Amount you will be required to repay (student loan + interest) Monthly payment amount: Year 1 = $240 Principal =$240 Interest = $ 60 Total = $300 $50 Minimum Payment IF YOU DO NOT PRACTICE IN NEVADA AS REQUIRED, YOU MAY OWE UP TO: Amount you may be required to repay (stipend grant + loan + interest) Triple Support Fee: 100% of support fee paid to school on your behalf x 3 Monthly payment amount: Year 1 = $ 2,400 x 3 Total = $ 7,200 Principal = $ 7,200 Interest = $ 3,300 Total = $10,500 $125 Estimated Repayment Schedule & Terms Payment Schedule: Interest Rate: Forbearance Period: Other Fees: Disbursement Date to Schools: Payment Due Dates: Student loan: 60 months / Stipend grant loan:96 months. 8% unsubsidized at time of disbursement. Grace period is 1 year from date of graduation. No payment is required during this time. Late fees, letter fees, return check fees, etc., are applicable. Please see your contract for details. Year 1: November / Year 2: August Monthly, following grace period. (OVER)

Page 7 Note: Due to federal regulations, we must provide you this information during the application, loan approval, and loan consummation stages. About the repayment example: The repayment example above is based on the best estimate currently available. It assumes in the first example that the borrower remains in school for 2 years and has a 1 year grace period before beginning payment. The second example reflects non-fulfillment of service obligation. Bankruptcy Limitations. If you file for bankruptcy you may still be required to pay back this loan. Forbearance period: Payments are not required, but can be made without penalty, during this time. Other loan options: Find out more about other loan options by contacting your school s financial aid office or the Department of Education at federalstudentaid.ed.gov. Should your WICHE support fee put you over the maximum student aid allowed, this amount may be subtracted from any federal support you may receive. Some schools have school-specific student aid terms not detailed on this form. Contact your financial aid office for more information regarding how your WICHE support will be allocated. Prepayment: There is no prepayment penalty for early payoff. However, you will be required to pay the outstanding accrued interest through the payoff date. The terms of the loan offer are good for 30 days. You have 30 days from the approval date to accept the lending offer during which the terms will not change. Further, you will have a 3-day right to cancel the loan. Contracts may offer additional terms and conditions. I HEREBY ACKNOWLEDGE RECEIPT OF THE LOAN DISCLOSURE STATEMENT. DATED: SIGNATURE: PRINT NAME A COPY OF THIS STATEMENT SHOULD BE RETAINED FOR YOUR RECORDS. Page 8