Treasure House - Woman's Board of Norwalk Hospital - Nursing Scholarship Application

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Norwalk Hospital Foundation
2011- 2012 Scholarship Application

PLEASE FILL OUT THE APPLICATION BELOW. PRINT IT OUT AND RETURN APPLICATION TO:

Please return this application
by May 13, 2011 to:

Norwalk Hospital Foundation
Scholarship Committee
34 Maple Street
Norwalk, CT 06856

All application packets must contain the following:
1. Completed, signed application
2. Formal letter/essay that includes the following:
   a. Why you chose nursing/health care as a career field
   b. Your career and educational goals
   c. Any extra-curricular or community activities, including any leadership roles
   d. Unusual circumstances, including financial need, for the committee to consider
3. Copy of your student transcript through the Spring 2011 semester
All questions must be answered. Please type or print clearly.

NAME OF SCHOLARSHIP FOR WHICH YOU ARE APPLYING: (see list on main page)

NAME:

ADDRESS:

CITY: STATE: ZIP CODE:

PHONE: (day) (evening) (cell)

E-MAIL:

MARITAL STATUS: Single Married Separated Divorced Widowed

NUMBER OF CHILDREN: AGES:

EDUCATIONAL INFORMATION:

HIGH SCHOOL ATTENDED: GRADUATION YEAR:

COLLEGE / UNIVERSITY ATTENDED: GRADUATION YEAR:

DEGREE:

COLLEGE OR UNIVERSITY YOU ARE CURRENTLY ATTENDING:

CURRICULUM PROGRAM (MAJOR):

# OF CREDITS PLANNED FOR FALL 2011:

# OF CREDITS PLANNED FOR SPRING 2012:

CURRENT GRADE POINT AVERAGE : EXPECTED GRADUATION YEAR:

NAME & TITLE OF FACULTY ADVISOR:

FINANCIAL INFORMATION:

ARE YOU EMPLOYED? NO YES (If yes, where:)

HOW MANY HOURS PER WEEK:

DO YOU PLAN TO CONTINUE EMPLOYMENT WHILE I THE NURSING EDUCATION PROGRAM?

Yes

ARE YOU CURRENTLY RECEIVING FINANCIAL ASSISTANCE OF ANY KIND? (If yes, list sources and amounts.)

HAVE YOU EVER RECEIVED FINANCIAL ASSISTANCE FROM THE NORWALK HOSPITAL, IE. TUITION REIMBURSEMENT, GRACE COLE JONES NURSING SCHOLARSHIP, WOMAN'S BOARD SCHOLARSHIP, OTHER ? (If yes, please list:)

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STUDENT SIGNATURE                                                                            DATE

If I receive a scholarship, I will write a thank you note to the scholarship donor and be available for a publicity photograph. I authorize the Foundation to provide personal data to the donor which will include, but is not limited to, name, GPA, degree program, current status.

Please return this application by May 13, 2011 to:

Norwalk Hospital Foundation
Scholarship Committee
34 Maple Street
Norwalk, CT 06856

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STUDENT SIGNATURE                                                                            DATE