Southside Health Education Foundation

Application for Financial Assistance

I. GENERAL INFORMATION

1. NAME ______

(Last)(First)(Middle)

  1. S.S. Number______–______–______BIRTHDATE ____/____/______
  1. MAILING ADDRESS ______

(Street)

______(City) (State) (Zip) Email address

4. ______/ ______/______

(Home Phone Number) (Cell Phone Number) (Work Phone Number)

5. STATE OF LEGAL RESIDENCE ______

6. DRIVERS LICENSE* STATE _____ NUMBER ______

* Please attach a photocopy of your current Driver’s License

7. RELIGION *______

* This is an optional question that you do not have to answer– some scholarships
request thisto be answered.

8. Do you have any legal dependents that rely on your financial support?

Yes ______No ______If yes, please list below:

Name of Dependent(s) / Relationship / Age

9. Are you a high school graduate? Yes ______No ______

Graduation Year ______GPA ______

Name of High School ______

Location (City and State) ______

If No, do you have your GED? Yes ______No ______Date ______

10. Are you currently enrolled as a student in a post-secondary health education program?

Yes ______No ______

If No, have you applied for admission to a college/university or post-secondary health education program?

Yes ______No ______

If No, please explain: ______

______

If you have been admitted to a college/university or post-secondary health education program but have not yet begun the program, please provide the name and address of the educational program that has accepted you and a copy of your acceptance letter and high school transcript:

______

If you are currently enrolled in a college/university or post-secondary health education program, please provide the name and address of the educational programalong with a copy of all high school and post-secondary program transcripts:

______

______

Course of study ______Status (full-time/part-time) ______

Current GPA ______Anticipated Graduation Date (month/year): ______

*Please attach official transcripts of allhigh school, college/university or post-secondary programs attended.Transcripts must be official.

11. Have you attended any other college/university or post-secondary program?

Yes ______No ______if yes, please complete the following:

Name of Institution / Dates Attended / Degree/Credential Received

12. Have you completed your Free Application for Federal Student Aid (FAFSA) form at: Yes ______No ______Date of completion ______

* Please attach a copy of the Student Aid Report (SAR) with this Application

13.Some financial assistance available through SHEF is provided in the form of a direct grant, and other financial assistance is available in the form of a forgiveable loan.Would you be interested in financial assistance that is a forgiveable loan conditioned upon your employment in a health profession immediately following graduation in the Petersburg or surrounding areas?

Yes ______*No ______(*by checking No, you will only be

considered for direct grant opportunities)

II. PERSONAL STATEMENTS

(Please submit answers to the following questions as a separate document. Include your name on the top of each page and number your answers clearly).

1. Why have you chosen a field in the health professions as your career choice?

(Your answer should be typed or printed and must be 300 words or more)

2.What field of healthcare do you hope to enter upon graduation?

3.Where do you plan to work following graduation?

(geographic location / type of facility)

4. What are your extracurricular activities, awards, honors or other distinctions?

III. CERTIFICATION STATEMENT

I certify that the information provided in this Application, including attachments, is accurate. I further certify and affirm that I will use any financial assistance provided by SHEFsolely for education-related expenses, including tuition, books, fees, and similar expenses. I understand that I may be required to satisfy additional conditions associated with a particular financial award, and that if such conditions exist, I will be notified of these conditions by SHEF and must agree to satisfy such additional conditions prior to receiving any funds.

______

(Student’s Signature)(Date)

Please return thecompleted Application to:

Southside Health Education Foundation

P.O. Box 867

Colonial Heights, VA 23834

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

APPLICATION CHECKLIST

Check if Completed

  1. All of the questions to the Application have been completed,
    and none are left blank (use “N/A” if necessary) ______
  2. The Personal Statements are typed or printed on a separate
    page and attached to the Application. ______
  3. A photocopy of your current driver’s license is attached. ______
  4. A copy of your Student Aid Report is attached. ______
  5. Official transcripts for all high school, college/university
    or post-secondary programs are attached. ______
  6. A copy of your acceptance letter ______