Western Missouri Medical Center Auxiliary

WESTERN MISSOURI MEDICAL CENTER AUXILIARY

HEALTH CAREERS SCHOLARSHIP

APPLICATION FORM

1. PERSONAL INFORMATION:

NAME: _______________________________________________________________

HOME ADDRESS: ______________________________________________________

CITY: _________________________________________________________________

ZIP CODE: __________________ PHONE: __________________________________

2. EDUCATIONAL EXPERIENCE:

GRADUATE OF (Include address and year graduated): ____________________________________________________________________________________________________________________________________________

NAME OF OTHER SCHOOL(S) OR COLLEGE(S) ATTENDED (Include dates):

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

GRADE POINT AVERAGE: ___________ GPA IN MAJOR FIELD: ____________

LIST CURRENT PROGRAM(S) YOU HAVE APPLIED FOR OR BEEN ADMITTED TO:

LIST DISTINCTIONS OR HONORS RECEIVED (SCHOLASTIC OR OTHERWISE):

CURRENTLY ENROLLED AT: _____________________________________________

INTEND TO ENROLL AT: ________________________________________________

IN (FIELD): ____________________________________________________________

FOR A DEGREE OR CERTIFICATE IN: _____________________________________

3. LIST TWO (2) REFERENCES:

NAME: ____________________________ ____________________________

ADDRESS ____________________________ ____________________________

____________________________ ____________________________

PHONE ____________________________ ____________________________

4. ATTACH RESUME AND LATEST TRANSCRIPT (include ACT scores).

5. ESTIMATED EDUCATIONAL EXPENSES FOR 1 YEAR:

TUITION FEES: ___________________________________________________

BOOKS / MATERIALS: _____________________________________________

ROOM / BOARD: __________________________________________________

TRAVEL EXPENSES: ______________________________________________

OTHER: _________________________________________________________

TOTAL: _________________________________________________________

I certify the information I have furnished is correct and complete to the best of my knowledge and belief with the understanding that it may be subject to verification with former employers and other persons. I understand and agree that misrepresentation, falsification, or omission may be considered sufficient cause for rejection. I authorize my past and present employers to supply any information they have concerning me or my work performance during my association with them and release them from all liability in connection therewith.

SIGNATURE _________________________________________ DATE ___________

Please complete and return to:

Community Relations

Attention: Teresa Collins

Western Missouri Medical Center,

403 Burkarth Road, Warrensburg, Missouri 64093

by April 1, 2009.