Virginia Health and Medical Science Educators

VIRGINIA HEALTH AND MEDICAL SCIENCE EDUCATORS

FACULTY SCHOLARSHIP PROGRAM

VIRGINIA HEALTH AND MEDICAL SCIENCE EDUCATORS ASSOCIATION

FACULTY SCHOLARSHIP APPLICATION

Directions: Print or type. Fill out form completely. If an item does not apply, put N/A for non-applicable in that space. Questions which require a Yes or No response should only have one box marked.

Year: 20__

I am applying for: Established Teacher Scholarship □ New Teacher Scholarship □

Name: ______

Last First Middle Initial

Address: ______

City: ______State: ______Zip______

Employer: ______

Address: ______

City: ______State: ______Zip: ______

Telephone: Work: ______Home: ______Cell: ______

E-mail: ______

Name of school where you work: ______

Your position title: ______

What subjects within Health Occupations do you teach? ______

______

______

Immediate Supervisor: ______Title: ______

Number of years in current position? ______

Have you held a similar position in another school district? If so, briefly describe this position: ______

______

______

VAHAMSEA Member: Yes □ Number of years ______No □

Describe your participation in VAHAMSEA activities, including those at the Region level: ______

______

______

______

______

Describe innovative approaches you have implemented in the classroom to create an effective and impactfullearning environment: ______

______

______

______

______

Should you wish financial to be considered, include an estimated budget (expenses) for the year in which you are seeking assistance. Attach your budget as a document to the application.

Degree you are seeking: ______

College or University you are attending: ______

Have you been officially accepted: ______

Have you been awarded any other scholarship/s for the year for which you are applying? Yes □ No □

If yes, please provide the name of the scholarship, the amount awarded, and the year of the award:

______

______

Application Due On or Before June 12 of the application year – must be postmarked or delivered to the address below by this date.

Send completed applications to:

Randall S. Mangrum, DNP, RN

Henrico County – St. Mary’s Hospital School of Practical Nursing

7850 Carousel Lane

Henrico, Virginia 23294

804-527-4660 Ext. 130

Application Certification:

I certify that the information on this application is accurate. I agree to allow the VAHAMSEA Scholarship Committee to contact individuals providing letters of recommendation or support if additional information is needed. I understand that if a scholarship is awarded, the funds awarded will be sent directly to the College or University.

Name: ______

Signature: ______

**For Established Teacher Scholarship**

I intend to retain my position as a VAHAMSEA Educator within Virginia for a minimum of 2 years following the scholarship award.

Name: ______

Signature: ______

**For New Teacher Scholarship**

I intend to retain my position as a VAHAMSEA Educator within Virginia for a minimum of 3 years following the scholarship award.

Name: ______

Signature: ______