110 4th Street SE, Suite B-8

Huron, South Dakota 57350

(605) 353-6315

2016

Fund for the Future

Scholarship Application

ScholarshipApplication Information

Instructions for completing this application – please read carefully:

  1. Complete all parts of the application and include a letter of reference. DO NOT LEAVE ANY ITEMS BLANK.Retain a copy of the application for your records.
  2. Submit this application form by 5:00pm, June 15, 2016 to the following address. Postal applications must be postmarked by this date while fax and email copies must be date stamped sent by this date:

Mail:HRMC Foundation

Attn: Fund for the Future Scholarship Program

110 4th St. SE, B-8

Huron, South Dakota 57350

Fax:1-605-353-7391 Email:

  1. Late/incomplete applications will not be considered unless there are no other eligible applicants.
  2. Applicants may apply for more than one category of scholarship fund(s).
  3. Applications will be considered on a rolling basis.

Eligibility Rules and Disclaimers:

  1. Applicant must be willing to sign a work agreement to return to the Huron area and work for Huron Regional Medical Center for a predetermined number of years as specified in the promissory note.
  2. Applicant must have a 2.5 High School GPA and maintain a 2.5 GPA in college.
  3. Applications will be considered on a rolling basis. This may affect availability.
  4. Preference is given to applicants from the Huron Regional Medical Center service areas.
  5. Preference is given to applicants who indicate financial need.
  6. The scholarship committee reserves the right to provide one or more scholarships, in varying amounts, to qualified applicants.
  7. If there are no qualified applicants, the scholarship committee will forego providing scholarships until the following year.
  8. Scholarship is based on need and may not be given every year.
  9. Failure to acknowledge acceptance of the award will result in award forfeiture.
  10. Falsification of information or violation of rules will result in withdrawal of all remaining scholarship funds.

Application

Please indicate the scholarship you are applying for(you may apply for more than one if eligible):

Medical Lab Science: MLT MT & MLT

Nursing: LPN RN to BSN BSN

Physical Therapy:

Radiology Technology: RT

Respiratory Care: CRTRRT

Ultrasound Technology:

Application – Please Complete All Sections:

Your Name:

Mailing Address:

Street/City/State/Zip Code

Cell Telephone #: Alt. Telephone #: Email Address:

High School Attended: Year Graduated:

University or Technical Institute attending or planning to attend (name/location):

College/program credits completed(anticipated):

Year in school or hours remaining in program:

Cumulative GPA (High School):

Cumulative GPA (College/Post-Secondary):

Expected College or Program Graduation Date:

Anticipated College Degree or Other Certification/Program(if enrollment is in a non-degree program, please provide additional information concerning type of program, etc.):

Use additional pages if needed and attach to this form:

  1. List College and/or High School honors (e.g., awards/honors, honorary societies, scholarships, etc. – including year(s) received).
  1. List all College and/or High School activities in which you participate (e.g., activity, year(s), office held, level of involvement).
  1. List your current and past work experience (e.g., employer, dates, responsibilities).
  1. List community, civic, volunteer or other types of activities. Can include religious activities.

5.Financial Statement (percentages only):

Support from family:%

Self-support:%

Support from grants:%

Support from college loans:%

Support from other scholarships:%

Other:%

Please explain:

Total:100%

6.Other Financial Information:

●Did you receive a Federal Pell Grant this year or last year?

●If yes, how much was awarded? $

●Did you receive a Federal Subsidized Student Loan this year or last?

●If yes, how much was received? $

●Do you have any special circumstances that impact your financial need?

●If yes, please explain:

7.How would receiving this scholarship help you attain your professional goals?

8.Why should you be awarded a scholarship over the other applicants?

9.Essay: “Why I want to work at Huron Regional Medical Center” (Please attach)

10.Please enclose a letter of reference from an individual not related or living with you.

11. Teacher References

Teachers Name: Phone Number:

Teachers Name:Phone Number:

By signing, I:

●Authorize the HRMC Foundation to contact my educational institution for additional information and to determine my enrollment status.

●Authorize the use of my name and image for use in advertising and press releases announcing my award if selected as a scholarship recipient.

●Agree to use the scholarship funds for the purpose of obtaining my degree or certification.

I attest, to the best of my knowledge, this application to be accurate and truthful.

SignatureDate

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