NURSING EDUCATION ASSISTANCE PROGRAM 2018 Nursing Scholarship Application

Transcription

1 NURSING EDUCATION ASSISTANCE PROGRAM 2018 Nursing Scholarship Application Dear Nursing Scholarship Applicant, The Baylor Scott & White Health (BSWH) Nursing Scholarship Program provides support for the education of nurses in Central Texas. Applications are accepted between April 16 and July 16, Please provide all requested items in the checklist. Checklist Application for Nursing Scholarship Program Most recent academic transcript, highlight GPA reflected on application (unofficial is acceptable) Professional reference as required (instructions found on pg 5&6) Recommendation from Supervisor (BSWH employee only) Applications will NOT be considered if they are: Turned in after July 16, MIDNIGHT Missing any item from the checklist Please Note: Use only the space provided Do not add extra pages or letters Page 1 of 8

2 I. Personal Information: A. Legal Name: Personal Address: Mailing Address: City: State: Zip: Cell Phone Number: ( ) B. Are you a United States Citizen? YES NO C. Are you a natural born US Citizen? YES NO D. Are you authorized to work in the United States? YES NO E. Have you served in the US armed forces? YES NO F. Prior education: Graduation Date Program Emphasis School Page 2 of 8

3 II. Education and Experience: A. Overall GPA reflected on most current transcript: B. Nursing school you are planning on attending: C. Nursing Program you wish to complete: LVN to ADN ADN ADN to BSN ADN to MSN BSN MSN Doctorate D. Nursing program enrollment date: (month & year) a. *Enrollment may not be pending at the time of application E. Nursing program anticipated graduation date: (month & year) F. Are you a member of a professional nursing or allied health organization? a. YES NO b. If yes, please list the name of the organizations: G. Do you hold a current State of Texas Nursing License? a. YES NO (If yes, please answer the following questions) b. Type of License: RN LVN c. Nursing License Number: H. Are you employed at Baylor Scott & White Health? a. YES NO (If yes, please answer the following questions) b. Date of Hire: Years of Service: c. Current Position: Department / Unit: d. BSWH Extension: e. Supervisor/Manager Name: FULL TIME PART TIME PRN Page 3 of 8

4 III. In the space provided, please share some of your educational and career goals: Page 4 of 8

5 To be completed for BSWH and non-bswh Employees IV. Professional Reference One - (Previous Colleague or Academic Faculty) Name of Candidate: Please rate applicant on items 1 through 4 and provide comments as needed: Scale: 1 Lowest 5 - Highest 1. Applicant has a strong work ethic: 2. Applicant demonstrates excellent leadership skills: 3. Applicant has an exceptional ability to relate to others: 4. Applicant has the ability to positively impact the profession of nursing: 5. How long have you known the candidate and in what capacity? 6. Please make any additional comments concerning the candidate that you feel would qualify him/her for consideration: Your name: Place of Employment: Title: Preferred Page 5 of 8

6 To be completed for non-bswh Employees ONLY! V. Professional Reference Two - (Previous Colleague or Academic Faculty) Name of Candidate: Please rate applicant on items 1 through 4 and provide comments as needed: Scale: 1 Lowest 5 - Highest 7. Applicant has a strong work ethic: 8. Applicant demonstrates excellent leadership skills: 9. Applicant has an exceptional ability to relate to others: 10. Applicant has the ability to positively impact the profession of nursing: 11. How long have you known the candidate and in what capacity? 12. Please make any additional comments concerning the candidate that you feel would qualify him/her for consideration: Your name: Place of Employment: Title: Preferred Page 6 of 8

7 VI. BSWH EMPLOYEES ONLY: RECOMMENDATION FROM SUPERVISOR I recommend (Name of applicant) for the BSWH Nursing Scholarship. The applicant has exhibited an overall satisfactory performance rating. Comments: Questions to be completed by supervisor Scale: 1 Lowest 5 - Highest 1. Attendance: 2. Problem Solving: 3. Team Player: 4. Would you hire into future nursing position? Yes No Supervisor Name: Supervisor Signature: Supervisor Unit and Title: Extension: Date: Page 7 of 8

8 VII. TERMS OF NURSING EDUCATION ASSISTANCE PROGRAM If, I receive a nursing scholarship, I agree and understand the following conditions: 1. To provide copies of grades within two weeks of the end of each semester. Grades must be scanned (as a PDF) and ed, to Naomi Thompson at Naomi.Thompson@BSWHealth.org 2. Any change in enrollment status must be reported, in writing, within 48 hours of the change. 3. Attendance of the Annual Scholarship Luncheon, held in November, is mandatory 4. Unless otherwise allowed by the assistance program I am awarded, 1 I agree to use the scholarship money solely for the payment of Qualified Expenses. Qualified Expenses shall mean tuition and fees required for enrollment or attendance in the Program and other fees, books, supplies and equipment required for instruction in the Program, but shall not mean general living expenses, such as room, board, travel or incidental living expenses. 5. I understand that I am solely liable for complying with any requirements for the reporting of the scholarship money as income and the payment of any applicable taxes, whether federal, state or local, that may be levied by any governmental authority on the scholarship money under this Agreement. 6. I agree that copies of my application and grades may be reported to the donor of the assistance program I am awarded. Signature of applicant: Date signed: Application and all documentation must be scanned and ed to Naomi Thompson at Naomi.Thompson@BSWHealth.org PLEASE DO NOT DELIVER IN PERSON OR MAIL 1 Lowther Scholarship permits a monthly allowance for living expenses. Page 8 of 8