Instructions and Required Materials

Scholarship application 2015

Instructions and required materials

Eligibility requirements for all scholarships can be found on Connection, on ghc.org, or by e-mailing . We cannot consider incomplete or unsigned applications. Omitting any of the required materials will eliminate your application from consideration.

Save a copy of the completed application for yourself, and send a copy along with the supporting materials described below to:

Interoffice mail: HR Service Center, ASB-1

U.S. mail: Group Health, HR Service Center, 12501 E. Marginal Way S., Tukwila WA 98168

E-mail:

Fax: 206-988-7750

Include the following supporting materials with your application:

• A typed letter (500 words or less) describing your:

• Personal situation.
• Community involvement.
• Need for financial assistance.
• Career goals.

• A plan of study or development plan.

• Two (2) letters of recommendation from someone outside your family who has known you for at least 2 years, or who can speak to your career potential. Must be typed, signed, and dated for the current year. Do not submit old recommendations.
  For the Vera K. Miller Scholarship for Career Development and the Katie Donahue Memorial Scholarship, one of the letters must be from a manager in your department.

• A copy of your transcript (official transcript not required) if currently attending school or a transcript from your most recently completed schooling

• For the Group Health Cooperative Academic Scholarship: If you are a volunteer (an alternative qualifying requirement), attach a letter from the Group Health volunteer supervisor you work under confirming that you have completed at least 150 hours of volunteer work. The volunteer supervisor can also write one of your two required letters of recommendation.

• For the Physician’s Assistant Endowed Scholarship:A typed response (500 words or less) to the question: “What is your vision regarding the role of PAs in clinical or leadership positions at Group Health?”

• For the Marc West “Remarcable” scholarship: A typed response (500 words or less) to the question: “How has the loss of a parent or having a parent with ALS impacted the direction of your education?”

Questions? Contact theHR Service Center, , or 206-988-7777.

Scholarship application 2015

Instructions

Type your responses into the boxes. Save as you would any Word document.

1) Check the scholarship(s) you are applying for:

☐Group Health Cooperative Academic Scholarship

☐Ethel Taylor Endowed Scholarship

☐Bernice Cohen Sachs, MD, Endowed Scholarship for Women Medical Students

☐Vera Miller Endowed Scholarship for Career Development

☐Katie Donahue Memorial Scholarship

☐Marc West “Remarcable” Scholarship

☐Physician Assistant Endowed Scholarship

2) Applicant’s name:Click here to enter text.

3) Street address:Click here to enter text. City, state, ZIP:Click here to enter text.

4) Work phone:

5) Home phone: (123-456-7890)

6)Group Health staff (employee or dependent:complete this question then move to question 8)

Employer: ☐ GHC ☐ GHO ☐ GHP ☐ KPS

Staff member’s name:Click here to enter text.

Staff member’s title:Click here to enter text.

Staff ID #:Click here to enter text.
(This number can be found in Employee Self-Service under My Job Profile, or on your Kronos timecard.)

FTE (e.g. 0.75, 1.0):Click here to enter text.

Hire date: Click here to enter a date.

Is the applicant a dependent of the staff member? (A dependent is someone who is claimed as an exemption on the staff member’s federal income tax. For further information, consult the IRS or read IRS Publication 929, Tax Rules for Children & Dependents, at irs.gov.)

☐Yes ☐No ☐Applicant is staff member

Is the applicant a child of a staff member?

☐Yes ☐No

7)Group Health Cooperative members (forGHC Academic Scholarship and Bernice Cohen Sachs applicants only)

Member name: Click here to enter text.

MemberID #: Click here to enter text.

Relationship of member to the applicant: Click here to enter text.

8)Financial status

a) If you are someone else’s dependent or have dependents of your own, please check the applicable box.

☐Dependent (your parents or guardians claim you on their tax return as an exemption)

☐Single (you are considered financially independent for income tax purposes)

☐Married (you file a joint tax return with your spouse)

b) Provide the total annual income from the previous year’s income tax form:

Parents/guardians...... $Click here to enter text.

Applicant...... $Click here to enter text.

Spouse...... $Click here to enter text.

Other...... $Click here to enter text.

TOTAL...... $Click here to enter text.

c)Please provide the number of dependents claimed on the tax return: Click here to enter text.

9) Are you receiving or requesting financial aid for your schooling from other scholarships, grants, educational or personal loans, tuition waivers, or a work-study program?☐Yes ☐No

If yes, list the other aid sources: Click here to enter text.

Note: The total of all scholarships awarded to you can’t exceed the total of your tuition and fees.

10) How did you learn about this scholarship? Click here to enter text.

11)Current or most recent program of study: Click here to enter text.

School: Click here to enter text.

Location: Click here to enter text.

GPA: Click here to enter text.

Graduation date (or expected graduation date): Click here to enter a date.

12)Planned program of study for 2015–2016: Click here to enter text.

School: Click here to enter text.

Location: Click here to enter text.

Type of program:☐Associate’s ☐Bachelor’s ☐Master’s ☐MD ☐Other doctorate

GPA:Click here to enter text. Expected graduation date:Click here to enter a date.

Approximate annual tuition & fees: Click here to enter text.

13)Have you received a Group Health scholarship before?☐Yes ☐No
If yes, please provide the scholarship name: Click here to enter text.

Affirmation and signature of applicant

I affirm that all information provided in this application is true and complete to the best of my knowledge.

Sign (in ink) ______Date ______

If the applicant is not the employee or member, the signature of the employee or member is required.

I affirm that all information provided in this application is true and complete to the best of my knowledge.

Sign (in ink) ______Date ______

Scholarship application, Page 1 of 3Revised: 10/9/18