Scholarship Application

PLEASE PRINT CLEARLY.

The goal of the Skaggs Foundation Scholarship Program is to meet community healthcare needs. There has been some changes so please carefully review the eligibility requirements and deadlines for scholarships available at www.SkaggsFoundation.org/scholarships. You may apply for either or both of these scholarships with this single application.

Today’s Date: ______Did you receive a scholarship from Skaggs Foundation last term? Yes No

Applying for Academic Term: □ Spring □ Summer □ Fall Year: ______Part-time or Full-time Student: PT FT

GENERAL INFORMATION
Full Name:
LAST / FIRST / MIDDLE INIITAL
Permanent Address:
NUMBER / STREET / APARTMENT
CITY / STATE / ZIP CODE
Current Address: If different from permanent address.
NUMBER / STREET / APARTMENT
CITY / STATE / ZIP CODE
Cell or home phone: / Work Phone:
Email Address:
EMPLOYMENT & VOLUNTEER HISTORY
Current Employer: / Position:
Supervisor: / Department:
How long have you been employed here? / Absences in last 12 months?
Any disciplinary action in last 12 months? / If yes, please explain:
Information provided will be confirmed with Cox Health HR for Cox employees.
Volunteer Experience:
Do you currently have a family member employed by Cox? No Yes Who? ______
EDUCATION HISTORY
Most recent school attended: / Dates Attended:
Highest level of education completed to date: / GPA:
If applicable, current course of study: / Expected graduation date:
EDUCATION PLANS
Desired field of study: / Proposed degree:
Starting date of program: / Hrs completed toward this degree:
Expected completion date: / Hrs remaining to complete degree:
College Student Status: / F So Jr. Sr. / Current GPA: Attach copy of transcript.
School: / Student ID #
Address:

Please be sure your submission packet is complete. All of the required items are due at the time of submission.

Checklist:

o  Completed application.

o  Most recent high school or college transcript (unofficial transcript will be accepted. No screen shots).

§  If college transcript is not available, attach proof of acceptance to an institution of higher education.

o  ** One-page essay on “Why you are interested in a career in healthcare?”

o  ** Letter of recommendation – by school advisor or work supervisor. Recommended must provide contact information with name, email address and phone number.
(** Not required for last term award recipients.)

All documents are to be mailed directly to the Skaggs Foundation at P O Box 650, Branson, MO 65615, faxed to 417-348-8009, or emailed to by deadline. Complete application packets are required at time of submission. Incomplete applications will automatically disqualified.

I affirm that the information provided on this application is true and complete and that I meet the scholarship criteria provided. I understand that if I am selected for the scholarship program, I will receive an award to help pay for my expenses to attend an accredited institution of higher education while pursuing the clinical healthcare degree/certification as outlined above.

Signature: ______Date:______