NURSING EDUCATION ASSISTANCE PROGRAM 2017 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 15 and July 15, 2017. Please provide all requested items in the checklist. Checklist Application for Nursing Scholarship Program Most recent academic transcript (unofficial is acceptable) Professional reference as required (instructions found on pg 5&6) Recommendation from Supervisor (S&W employee only) Documentation that you are enrolled in a School of Nursing Applications will NOT be considered if they are: Turned in after July 17 Missing any item from the checklist Submitted with items not on the checklist Please Note: Use only the space provided Do not add extra pages or letters Page 1 of 8
I. Personal Information: A. Legal Name: Personal E-mail 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
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) 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 Email: e. Extension: FULL TIME PART TIME PRN Page 3 of 8
III. In the space provided, please share some of your educational and career goals: Page 4 of 8
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 Email: Page 5 of 8
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 Email: Page 6 of 8
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
VII. TERMS OF NURSING EDUCATION ASSISTANCE PROGRAM If I receive a nursing scholarship, I agree to the following conditions: 1. To provide copies of grades within two weeks of the end of each semester. Grades must be scanned and emailed. 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. Signature of applicant: Date signed: Application and all documentation must be scanned and emailed to Naomi Thompson (E-mail address noted below). PLEASE DO NOT DELIVER IN PERSON OR MAIL Naomi Thompson Administrative Supervisor Corporate Office of the Chief Nurse Executive (CTX) Telephone: 254-724-4389 E-mail: Naomi.Thompson@BSWHealth.org Page 8 of 8