River Falls Area Hospital Auxiliary

Application # ______

(Office use only)

River Falls Area Hospital Auxiliary

1629 East Division Street

River Falls, Wisconsin 54022

SCHOLARSHIP APPLICATION FOR HEALTH RELATED CAREERS

River Falls Area Hospital Auxiliary is proud to offer three scholarships each year for tuition and books to deserving students entering the health care field. All of our scholarships are funded by donationsto the auxiliary and through various fundraisers. Scholarships are limited to graduating seniors from River Falls High School and to children of employees, auxiliary members or volunteers attending Pierce and St. Croix Falls countyhigh schools.

The following criteria for evaluating the scholarships will be applied:

1. Volunteer services (inside and outside hospital)

1. Personal and professional goals

1. Grade point average 3.0

1. Work experience

1. Pursuing health related fields

1. References

1. Bonus points maybe given to relatives of RFAH employees and auxiliary members

1. Quality of application

The selection committee will not know the applicant’s name when reviewing their application. Please do not put names on the reference forms.

All applications must include the following items or the application will not be considered. This should also be neat, thorough and typed:

1. Transcript of high school grades
2. Letter of acceptance from college or vocational school
3. Two characterreferences.

*Please use the enclosed forms when requesting character references. The references must be non-relatives and may include teacher, member of clergy, employer, co-worker, etc. The references will be included in the application packet to be submitted no later than March 31, 2017 at 4:00p.m.

TO THE APPLICANT:

By completing the information required in this application, you enable us to determine your eligibility to receive funds provided specifically to help students planning to go on to higher education and who otherwise satisfy the evaluation criteria developed by the River Falls Area Auxiliary.

• You must complete your sections of this application at your earliest convenience.
• Forward the appraisal forms with a stamped self addressed envelope to the persons you have selected to complete the appraisal. The form must then be returned to you sealed with the appraiser’s signature across the seal on the back of the envelope. You may select a teacher, employer, member of the clergy, job supervisor or any other person in a position to evaluate you according to the criteria given.
• You are responsible for seeing that all supporting documents are submitted to the River Falls Hospital Auxiliary.
• Only those applications found to be complete by the deadline will be processed.
• Completed Forms and recommendations must be received by March 31, 2017 at 4:00 pm
• Applications should be sent to: River Falls Area Hospital Auxiliary

ATTN: Scholarship Chairman

1629 East Division Street

River Falls, Wisconsin 54022

9/16/15

Applicant Data (please print) Application#______

(office use only)

______

NAME (last) (first) (mi.)

______

Permanent address (street) (city) (sate) (zip)

______

Cell Number Home Numbere-mail address

Name of Parent/Guardian______

Permanent mailing address of parent or guardian if different from applicant

______

(street) (city) (state) (zip)

Personal Data

Describe your work / volunteer experience in the last four years. Indicate months of employment for each job and approximate number of hours worked each week. Please include contact phone number for verification.

Company Name Position Total months worked Hours per week Contact and Phone #

9/16/15 (1)

Personal Data cont’d_

Name of the college, university or technical school you plan to attend

*Please attach a copy of the acceptance letter to this application

Make a statement concerning your plans as they relate to your educational and career objectives and further goals. Limit your answer to this space please.

What motivated you to pursue a health care profession?

(2)

Do you have a parent or grandparent employed at River Falls Area Hospital or a member of the RFAH

Auxiliary? ______Name______

Why do you feel you deserve this scholarship?

9/16/15(3)

School Data

School attended______

School Address______( )______

(street)(city) (Telephone)

Graduation date Month______Year______

Name of High School Principal______

Name and address of post secondary school you will be attending in the fall

Name______

Address______

Major field of study applicant has an interest in

1. ______

2. ______

3. ______

Transcript Information

All applicants must include a transcript of grades and have the following section completed by the appropriate school official

Applicant ranks ______in a class of______

Cumulative grade point average______/4.0 scale.

______

School official signaturetitledatephone

9/16/15(4)

Transcript Release

Date______

I give my consent to release a copy of ______’s

High school transcript to the scholarship committee of the River Falls Area Hospital Auxiliary.

(Student signature if student is 18 years old)

(Parent / guardian signature if student is under 18)

Disclaimer

I approve of publishing my name in any publication announcing my scholarship.

In submitting this application, I certify the information provided is complete and accurate to the best of my knowledge. Falsification of information may result in the termination of the scholarship grant. I also agree to submit my senior picture if I am selected for this scholarship.

______Date______

(student signature)

9/16/15(5)

Student Application Check List

______Pages 1-5 of application completed

______Letter of acceptance from post-secondary option

______Current transcript from graduating high school

______Applicant appraisal #1 in signed sealed envelope

______Applicant appraisal #2 in signed sealed envelope

______All appropriate areas signed and dated

______E-Mail

Should you have any questions, please contact the Auxiliary President by email:

Application # ____

(office use only)

To Student: Applicant Appraisal Sheet (required)

You are encouraged to have this form completed by a teacher, an employer, member of the clergy, a job supervisor or any other person who is in the position to evaluate you according to the criteria given.

To the Appraiser:

You have been asked to provide information in support of this application for a scholarship. Please give immediate and serious attention to the following statements. Circle the answer that best describes the individual being considered for this scholarship. Please indicate if you have no basis for evaluation for any of the statements. When completed place the form in the provided envelope, seal and write your name across the sealed portion; return to student so they can submit with his/her application.

The applicant’s choice of post secondary education program is

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant’s achievement reflect his/her ability

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant’s ability to set realistic and attainable goals is

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The quality of the applicant’s commitment to school and community is

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant is able to seek, find and use learning resources

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant demonstrates initiative

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant demonstrates curiosity

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant demonstrates good problem solving skills

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant follows through and completes tasks

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

The applicant demonstrates good problem solving skills; follows through and completes tasks

The applicant’s respect for self and others is

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

continued on the back

CommentsPlease. (Do not name student)

Appraiser’s signatureDate Phone

SCHOLARSHIPS AVAILABLE TOGRADUATING HIGH SCHOOL SENIORS

POLICY

River Falls Area Hospital Auxiliary is sponsoring one $1,000.00 scholarship to River Falls High School graduating seniors who are planning to attend an institution of higher education to pursue a career in a health-related field. Two additional scholarships will be awarded to an applicant going into a health field who could have a parent who is an employee, auxiliary member or volunteer of RFAH attending a high school in Pierce and St. Croix County.

PROCEDURE

Selection will be based on academic achievement, service to the school and community and work.

Selection will be determined by River Falls Area Hospital Auxiliary Scholarship Committee. The selection will be based on the quality of the application, GPA, volunteering, work experience, references, personal goals and entering a health care field.

Names of the applicants and any other personal identifying information shall be blacked out so that committee members who are reviewing the applications will not be aware of who the student is.

Committee will use the attached form for the point system when reviewing applicants.

The scholarship form will be available to applicants on Feb. 1 of each year. It will be on the Auxiliary web site, will be publicized at the River Falls, high school, will be included in their weekly written newsletter available to all students, will be in the auxiliary and RFAH employee newsletters, in the local newspapers, on the Ronin screen at RFAH,and requested by the Auxiliaries e-mail address which is: riverfallsauxiliary.com.

Scholarship winners will be announced at the high school awards ceremony in May.A member of the Auxiliary will present each award. In April, someone from each high school guidance office will contact the chair of the scholarship committee with the date, time and location of the event along with any pertinent details and a request for the name of the presenter.

After the scholarship recipient has completed one semester, he/she must submit their post-secondary grades, tuition statement and the address of the college where the money is to be sent. A check will be sent directly to the college.

THE SCHOLARSHIP WILL BE FORFEITED IF NOT CLAMED BY

THE ENDOF THE FRESHMAN ACADEMIC YEAR.

Scoring Matrix for RFAH Auxiliary Scholarship

20 points for transcript

Transcript is complete and reflects three and one half years of coursework

1….2….3….4….5______

Transcript reflects grades in the above average (A,B) range.

1….2…3…4…5______

Transcript reflects course choices that are challenging throughout the 4 years of high school

1….2….3….4….5______

Transcript reflects a variety of science and health related classes

1….2….3….4….5______

20 Points for Essay

Essay is typed, written clearly and illustrates good grammar skills

1….2….3….4….5______

Essay addresses the topic and presents a logical and convincing argument for why they are deserving of the scholarship.

1….2….3…..4…..5…..6….7….8….9….10….11….12….13…14…15

______

20 Points for Volunteering, work experience and references

Work experience is varied and extensive

1…..2…..3…..4…..5______

Has volunteered in a variety of ways including opportunities in health related areas

1…..2…..3…..4…..5______

References reflect good character, motivation, and likelihood to succeed.

1…2….3…..4….5…..6….7…..8….9…..10______

10 points Volunteer at RFAH or other area health facility

Student has volunteered on a regular basis at RFAH or another area health care facility

1…..2…..3…..4…..5…..6…..7…..8…..9…..10 ______

5 points

Parent is an employee, member of auxiliary or volunteer at RFAH

______

Point Total ______

Fill in the date….

River Falls Area Hospital Auxiliary

1629 East Division Street

River Falls, WI. 54022

____name______

River Falls High School

The River Falls Area Hospital Auxiliary is proud to present you with a $______scholarship to apply to your education in a health-related field. We commend you on your academic success and your service to school and the community.

As soon as you receive your first semester statement and transcripts, please send copies to the name and address listed below. The River Falls Area Hospital Auxiliary treasurer will then send a check to your college. You must also include the name and address of the office to which the scholarship funds are to be sent.

The scholarship will be forfeited if those actions are not completed by the end of your freshman academic year.

Best wishes as you begin studies in your chosen field.

Sincerely,

Glenda Zielski

River Falls Area Hospital Auxiliary Scholarship Committee Chairperson

N7951 980th Street

River Falls, WI. 54022

715-307-2782