CROSSING RIVERS HEALTH SCHOLARSHIP

APPLICATION FORM

APPLICANT: This form must be completed for consideration to receive a Crossing Rivers Health Scholarship for education in a health occupation, with the exception of those pursuing medical school. Please complete the application with the help of your high school and submit it to the office of the Chief Executive Officer at Crossing Rivers Health no later than Friday, March 17, 2017.

ATTACHMENTS: 1. Essay stating your intent to pursue a health occupation and why

(must be approximately one page in length).

2. Letter of Recommendation

NAME PARENT/GUARDIAN

TELEPHONE ADDRESS

CITY STATE ZIP

SSN HIGH SCHOOL

HIGH SCHOOL ADDRESS

CITY STATE ZIP

HEALTH OCCUPATION COURSE OF STUDY

COLLEGE WILL BE ATTENDING

TELEPHONE ADDRESS

CITY STATE ZIP

**THE INFORMATION HEREIN IS TRUE TO THE BEST OF MY KNOWLEDGE**

*Any Willful Misrepresentations May Disqualify the Applicant*

STUDENT'S SIGNATURE DATE

PARENT OR

GUARDIAN'S SIGNATURE DATE

PRINCIPAL OR

COUNSELOR'S SIGNATURE DATE

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OBJECTIVE CRITERIA

I. College entrance examination score (ACT or SAT)

ACT composite score and/or SAT combined score

II. Student's cumulative high school grade point average (GPA) using a 4.0 base.

III. Please attach High School transcript.

IV. Total number of family members living at home (including yourself):

Number of dependents in your parent's family (including yourself):

Ages (including yourself) No. Attending College (including yourself)

Estimated Tuition Expense per Semester

V. Extracurricular Activities – Organizations and Clubs (Show years of involvement; also, please indicate any offices held):

Honors and Awards

Community and Other Activities

VI. Work Activities – Are you employed? Yes No

If yes, what type of work and how many hours per week?

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CROSSING RIVERS HEALTH SCHOLARSIP

RULES AND REGULATIONS

TITLE: Rules and Regulations Governing Scholarship Awards

PURPOSE

AND

OBJECTIVE: The Scholarship Committee of Crossing Rivers Health hopes to aid educational endeavors of the service area's youth by offering scholarships to area graduating high school seniors. These scholarships will be offered in the form of grants to students who aspire to continue their education in a health care occupation, with the exception of those intending to apply for medical school. It is the committee's intent that this program will promote higher education in the health care occupations. It is considered an investment for continued professional staff recruitment at Crossing Rivers Health and those facilities operated by Community Health Services Corporation.

Following are the guidelines for governing the scholarship program:

1. The Scholarship Committee of Crossing Rivers Health will award scholarships each year to qualifying students who are pursuing higher education in a health care occupation. The number of scholarships awarded for health occupations will be based upon the finances available in the scholarship account. The maximum amount of a scholarship is $8,000.

2. Scholarships for health occupations shall be awarded to graduating high school seniors from the hospital’s health care service area.

3. The Chief Executive Officer or his designee will contact the area school guidance departments regarding the availability of the scholarship program.

4. Selected scholarship applicants, along with their parent(s) and/or guardian(s), will be interviewed by Crossing Rivers Health’s Scholarship Committee or a designee. The Chief Executive Officer or his designee will also contact the respective school guidance counselor regarding applicants for the scholarship.

5. Scholarships will be awarded based upon the following criteria (not necessarily listed in the order of importance):

a. Scholastic Ability (class standing, extra curricular activity)

b. Administrative Interview and Recommendation

c. Applicants must be accepted into or enrolled in a health occupation program.

d. Future employment at Crossing Rivers Health or those facilities operated by Community Health Services Corporation will be given important consideration in awarding the scholarships.

6. The Scholarship Committee of Crossing Rivers Health will review and make the final decision on the awarding of scholarships.

Crossing Rivers Health

Scholarship Rules and Regulations

Page 2

7. The Crossing Rivers Health Scholarship Committee shall be responsible for investing scholarship funds in a timely manner; all accounting and reports relating to the scholarship fund shall be prepared by the Chief Executive Officer or his designee.

8. Scholarship funds will be paid directly to the college designated by the recipient with the first year payment being submitted at the beginning of the second semester. Subsequent payments will be submitted at the beginning of each of the following semesters. Total payments will not exceed $8,000.

9. A commitment of employment at Crossing Rivers Health or those facilities operated by Community Health Services Corporation is a condition of the awarded scholarship. Scholarship funds are forgiven at the rate of $1.50 per hour for each hour worked as an employee. If there is not a position available within 60 days of graduation, the loan is forgiven in its entirety.

10. Recipient must maintain good progress and academic standing in the program. Nonconformance or withdrawal from the program will require immediate payback of all funds to Crossing Rivers Health. The balance due shall include the principal plus interest computed at an annual rate and compounded quarterly from the date of disbursement.

11. All applications become the property of Crossing Rivers Health.

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