Jefferson County Hospital Auxiliary

JEFFERSON COUNTY HOSPITAL AUXILIARY

SCHOLARSHIP APPLICATION FOR A RECENT HIGH SCHOOL GRADUATE

The purpose of the scholarship is to give financial aid to an individual who is interested in any of the health related fields.

CONTRACT STIPULATIONS:

Applicant, if awarded a scholarship, will be expected to sign a formal contract, agreeing to:

1.  Purse an education in a health related field at an educational institution

acceptable to the Auxiliary.

2.  Repay Jefferson Country Hospital Auxiliary all sums advanced in the event that the year or specified period of study is not completed.

INSTRUCTIONS TO THE APPLICANT:

A.  Applicant’s Qualifications:

1.  A 2.5 grade point average must be maintained in high school.

2. Applicant must be interested in receiving and education in a health related field.

3. The recipient of the scholarship must maintain a yearly average of at least 2.0 (based on 4.0) grade average in order to continue to be eligible for the scholarship.

4.  Applicant must be a resident of Jefferson County, IA.

B.  The Applicant must stare family’s ability (or spouse’s ability) to contribute to the applicant’s education over a period of one year.

PLEASE OBSERVE THE FOLLOWING INSTRUCTIONS:

1. The scholarship will not be awarded until the applicant selected has been accepted

by the school of their choice.

2.  When the final scholarship is awarded and the contract is signed, it must be

signed by the recipient, his/her parents, spouse, or guardian.

3.  The money is given directly to the college or university registrar.

4. Please submit this application to your guidance counselor by April 15, 2011.

JEFFERSON COUNTY HOSPITAL AUXILIARY SCHOLARSHIP

RECENT HIGH SCHOOL GRADUATE

NAME OF APPLICANT:______

ADDRESS:______CITY:______ZIP CODE:______

TELEPHONE NUMBER:______DATE OF BIRTH:______

FATHER’S NAME:______MOTHER’S______

OCCUPATION OF FATHER:______

OCCUPATION OF MOTHER:______

NUMBER OF DEPENDENTS IN FAMILY:______AGES:______

CLASS RANK:______OUT OF ______GPA:______

PLEASE ATTACH A COPY OF YOUR HIGH SCHOOL TRANSCRIPT.

NAME AND ADDRESS OF SCHOOL YOU PLAN TO ATTEND:

HAVE YOU BEEN ACCEPTED?______

PROGRAM OF STUDY PLANNED:______

COST OF SCHOOL:______TUITION:______ROOM/BOARD:______

STATE YOUR FAMILY/SPOUSE’S ABILITY TO CONTRIBUTE:______

STATE YOUR ABILITY TO CONTRIBUTE: ______

WHAT ARE YOUR EDUCATIONAL GOALS?

DO YOU WORK AND IF SO WHERE?______

COMMUNITY, SCHOOL, CHURCH ACTIVITIES:

HAVE YOU BEEN AWARDED ANY OTHER SCHOLARSHIP OR FINANCIAL AID?

IF SO, PLEASE LIST FROM WHOM AND AMOUNT OF EACH.

ATTACH 3 LETTERS OF RECOMMENDATION FROM TEACHERS, EMPLOYERS, OR SOMEONE INVOLVED IN YOUR ACTIVITIES.

DATE OF APPLICATION:______

SIGNATURE OF APPLICANT:______