SCHOLARSHIP APPLICATION

Please print or type legibly when completing this application. Neatness, completeness and overall presentation of your application will be used in the selection process. IMPORTANT NOTE: APPLICATIONS COMPLETE WITH ALL ATTACHMENTS, MUST BE RECEIVED BY MARCH 31STOF2018TO BE CONSIDERED.

Personal Information:

Name______

First Middle Last

Mailing Address

City StateZipPhone______

Email Address______

CurrentEmployer or School______

Future Degree/Course of Study

______

Name of School (applicant mustdesignatewhere scholarship will be used) ______

Work or Volunteer Experience:

Organizational Memberships & Community Service:

Awards & Honors Received:

Other Financial Aid:

Name of parent(s) or spouse(for inclusion only in the scholarship winners’ press release/Foundation Annual Report)

______

Eligibility:

Scholarship applicants must be accepted or currently enrolled in an accredited program of a recognized healthcare school (Note school should be listed on previous page). Applicants must be residents of or attending school in the Columbus area and have at least a 2.50 Grade Point Average. It is the intent of the scholarship donors to award these scholarships to highly qualified individuals who have a desire to use their abilities to further serve the healthcare needs of the ColumbusCommunityHospital service area. Applicants will ideally make themselves available to work at the ColumbusCommunityHospital as school workload permits.

Attached:

□Transcript—from current semester illustrating current and cumulative G P A.

□Enrollment Verification: Submit a copy of your acceptance letter or other proof of acceptance into an accredited healthcare program from a recognized college, university or other accredited learning institution.

□Future Goals. Submit a brief essay on a separate page identifyingyour career plans, dedication to career, contributions you plan to make to your career and availability for work at the hospital.

Please check Scholarship(s) you are applying for:

□CCH Foundation Scholarship – The CCH Foundation Scholarship was established in 2017. $500 will be awarded to a qualified student furthering his/her education in any health care field. Preference will be given to a CCH employee or the child or grandchild of any employee.

□High School Student Scholarship–The CCH High School Student scholarship was established in 2008. $300 will be awarded to a qualified high school student taking a C N A or other entry level healthcare course to support development of our area youth.

□The Dwayne Willers Memorial Scholarship – The Dwayne Willers scholarship was established in 2013by Dwayne’s family. $300 will be awarded to a qualified student who is pursuinga career inthe field of Radiology.

□The William and Barbara Gerhold Scholarship: The Gerhold scholarship was established in 2006 by long-time residents, Barbara and William Gerhold. $500 will be awarded to a qualified student to help foster educational achievement and service excellence among CCH employees (and children) in the NURSING field.

□The George Prochaska Scholarship: The Prochaska scholarship was established in 2006 by the family of the late George Prochaska. Two (2) $500 scholarships will be awarded to recognize educational achievement by CCH employees(and children)in afield designed to enhance the Mission of the Columbus Community Hospital.

□Eagles Scholarship: The Fraternal Order of Eagles #1834 Aerie & Auxiliary scholarship was established in 2006. $1,000 will be awarded to a Current CCH employee who is currently enrolled in healthcare educational course in recognition of academic achievement. Preference shall be given to candidates in our Radiology Dept.

□HDR Scholarship:The HDR Scholarships were established in 2007 to assist students of Central Community College - Columbus Campus. $500 each will be awarded to two students who are pursuing careers in healthcare. Preference is given to students who plan to attend Central Community College – Columbus Campus.For one scholarship, preference is given to a student who is proficient in Spanish.

Signature of Applicant: Date

Revised 01-31-2018