2017-18 Lakeview Health Foundation Scholarship Guidelines and Application 1
Health & Wellness Education Scholarship Program: Thank you for your interest in the Lakeview Health Foundation Health & Wellness Education Scholarship Program. The Friends of Lakeview Hospital established this fund in 1961 to assist local students pursuing an advanced education in medicine or nursing, as well as to thank the community for its tremendous support of Lakeview Hospital over the years. This program has changed and expanded over the years to recognize the ongoing needs of both our community and our hospital for qualified, caring healthcare delivery professionals, who would be employable within the Lakeview Health System. In November 2008, The Friends of Lakeview merged with the Lakeview Health Foundation. The Foundation is honored to carry on the mission of The Friends, including the healthcare scholarships (now known as the Health & Wellness Education Scholarship Program). Eligibility Applicants must meet one of the following criteria: 1. Be a resident of: Afton 55001, Bayport 55003, Houlton 54082, Lake Elmo 55042, Lakeland 55043, Mahtomedi 55115, Marine on St. Croix 55047, Oakdale 55128, Somerset 54025, Stillwater Area 55082 (inclusive of entire 55082 zip code area) or White Bear Lake Area (inclusive of all 55110 zip code area). 2. Or, be an employee of Lakeview Health or the child of a current employee; 3. Or, have had a history of volunteering at Lakeview Health or Lakeview Health Foundation. Volunteer hours must be confirmed by the hospital s office of volunteer services or Foundation staff. The applicant must be accepted at an accredited college or technical school in the major program of study (see eligibility chart). Students must be already accepted into a program. For example, if you are a pre-med student or a pre-nursing student, you are not eligible for a Lakeview Health Foundation Health & Wellness Education Scholarship until you are accepted into medical or nursing school. If you expect acceptance notification after the March 31st deadline, but prior to June 1 st, you are encouraged to apply, pending acceptance. Scholarships will be awarded to those who are enrolled in a minimum of an Associate Arts degree program in a healthcare delivery field (see eligibility chart), subject to the review of Lakeview Health Human Resources department. For example, a CNA program would not qualify. The Application You must complete the application. Please be thorough; incomplete forms or applications with missing attachments or signatures will not be accepted. You must write a personal statement, obtain two letters of recommendation, and include your most recent official school transcript. Please be certain to include information and references about your community activities and volunteerism/community service. The Application Deadline Your application and required forms must be received at Lakeview Health Foundation, 927 Churchill Street West, Stillwater, MN 55082 by March 31, 2017. If you have questions, please call the Foundation offices at 651-430-8731 or foundation@lakeview.org. The Selection A committee with representatives from the Lakeview Health Foundation Board, Scholarship & Grant Review Committee and Staff will review the applications. All first time applicants will be expected to attend a brief interview with the committee, which will be held at Lakeview Hospital. The interview invitation will come via an email. Keep in mind that the committee will consider your personal statement, recommendations, scholastic ability, and volunteerism/community service. Once awarded a scholarship, you must reapply annually. However, only first time applicants are interviewed. 2
Distribution of Scholarship Funds Scholarships will be awarded for the upcoming academic year and sent directly to the bursar s/tuition office at your school during the month of July or August. Be sure you have included the correct name and mailing address for that office on your application. Funds may be used for tuition only. If your education plans change after you have been awarded a scholarship and disqualify you from receiving a Lakeview Health Foundation scholarship, any funds that have been disbursed to your school must be immediately returned to Lakeview Health Foundation. External Communications We ask that all recipients provide Lakeview Health Foundation with copies of external communications regarding their scholarship (other than those generated by Lakeview Health), including information published in local newspapers, TV news, or corporate/school newsletters, etc.). When the scholarship is accepted by the recipient, the recipient agrees to participate in any Lakeview Health System communications regarding scholarship disbursals. Please sign the application media consent line. If you would like a press release/photo mailed to your educational institution or another publication, please provide the request and media contact information to the Foundation - foundation@lakeview.org 2016 Honorary Scholarships include: 1) The Alice Anderson Nursing Scholarships, which honor Alice Anderson, a former Lakeview nurse; $500 - $1,000 grants, in general, are awarded to nursing students. 2) The Jo Dickinson Scholarship, in honor of Jo Dickinson who founded the scholarship; $2,000 is given to a nursing student in the final year of a bachelor degree program who can demonstrate a commitment to his/her community, either locally or at college. 3) The Bonnie Nutting Scholarship, established in 2000 in honor of Bridge Marathon Coordinator Bonnie Nutting. $2,000 will go to medical education students. 4) The Dr. Doug Allen Scholarship established in 2016 in memory of Lakeview physician Dr. Doug Allen, a scholarship of $1,000+ will go to an M.D. or D.O. medical student. 5) The Dr. David Wettergren Scholarship, established in 2009 in honor of long-serving System and Hospital Board Chairman David Wettergren; $2,000 will go to a senior health careers student in an associate degree program, or higher, who can demonstrate a commitment to his/her community, either locally or at college. 3
ELIGIBILTY CHART (Based Upon a Full-Time Student) Degree/Program 4 Lakeview Health System Employee Eligibility Non-Employee Scholarship Eligibility Audiologist All years Dietitian Medical Doctor MD, DO All 4 Years All 4 Years Medical Technician ( allied health professional ) Lab, Paramedic, Pharmacy, PT, Radiology, Respiratory, speech, etc. Nurse (2 years) RN (2) Nurse (3-4 years) Bachelor Degree (4) Nurse (Masters) Advanced Practice (2/3) Occupational Therapist Parish Nurse Pharmacist Contact Foundation Staff Physical Therapist DPT Physicians Assistant PA
Speech Therapist OTHER Please contact Foundation 651-430-8731 or foundation@lakeview.org All applicants must provide letter of acceptance in their degree program Transcript must reflect /school listed on application. Each degree program will have maximum #/years of award limit, as determined annually by the Foundation. Part-time applicants may receive additional questions from Committee regarding proposed length in program and credit hours per year, etc. Committee will determine maximum number of times a student may receive a scholarship, based upon the degree applied for and whether they are PT or FT students. 5
APPLICATION DATE: o New Applicant 2017 o Returning Applicant APPLICANT LAST: FIRST: MIDDLE EMAIL: HOME: ADDRESS: CELL PHONE: CITY: STATE: ZIPCODE: PRESENT ADDRESS (if different): CITY: STATE: ZIPCODE: DATE OF BIRTH: COLLEGE STUDENT ID # SOCIAL SECURITY # (required to issue check): ELIGIBILITY (Check One!) RESIDENT or RECENT GRADUATE OF PUBLIC HIGH SCHOOL IN: 54025, 54082, 55001, 55003, 55042, 55043, 55047, 55082, 55110, 55115, 55128 LAKEVIEW HEALTH EMPLOYEE DEPARTMENT: CHILD OF LAKEVIEW HEALTH EMPLOYEE VOLUNTEER @ LAKEVIEW HEALTH or LAKEVIEW HEALTH FOUNDATION EDUCATION YEAR OF HIGH SCHOOL GRADUATION HIGH SCHOOL ATTENDED, CITY/STATE UNDERGRADUATE INSTITUTION NAME/DEPT.: DATES: YEAR IN SCHOOL o FRESHMEN/1st o SOPHMORE/2nd o JUNIOR/3rd o SENIOR o SENIOR+ COURSE OF STUDY (MAJOR AND MINOR) ANTICIPATED and/or GRADUATION DATE MO/YR GRADUATE OR MEDICAL INSTITUTION NAME DEGREE PLANNED LENGTH OF PROGRAM (YEARS, FT) ANTICIPATED GRADUATION DATE MO/YR EDUCATIONAL INSTITUTION TUITION OFFICE ADDRESS OR CREDITS REMAINING TOTAL # OF FT CREDITS NEEDED TO GRADUATE CREDITS REMAINING CITY STATE ZIPCODE APPLICATION FOR(!all that apply): o FALL 2017 # of Credits o SPRING 2018 # of Credits o SUMMER 2018 # of Credits o OTHER # of Credits (i.e. January Term) STUDENT STATUS (during scholarship period): If PART-TIME, Explain schedule plan for fall 2017 - o FULL-TIME or o PART-TIME summer 2018 (Use back of page, if needed) 6
List extra-curricular activities, hobbies/talents, outstanding recognition and achievements, and volunteerism/community service: (May include volunteering @ church or in a school classroom. Please use additional paper if necessary) 1 2 3 4 5 RECOGNITION/OUTSTANDING ACHIEVEMENTS 1 DATE(S) 2 3 4 5 VOLUNTEERISM/COMMUNITY SERVICE DATE(S) DESCRIPTION HOURS 1 2 3 4 5 7
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Attach this Check List to Scholarship Application Form: APPLICATION CHECKLIST LAST NAME, FIRST Reminder - place this form on the top of the application Copy the application and attachments for your own records. Attach a personal statement (not to exceed one typewritten page) of your educational plans as they relate to your career goals. Please report any unusual family or personal circumstances which you think warrant consideration. State why you are applying for this scholarship. Attach two current letters of recommendation. Attach your latest official college transcripts (sealed school envelope or school may send directly to Foundation office) Attach your college W-9 form (request from Bursars/tuition/finance office of your college). THIS MUST BE FROM/SIGNED BY THE SCHOOL NOT THE STUDENT. Email foundation@lakeview.org, if the school will not release it. Sample below: SAMPLE W-9 Lakeview Employees only - Attach letter of acceptance, IF this will be your first year in the program for this degree path. Lakeview Health System Volunteers Include dates of service and total number of hours on previous page. Sign and attach photo/interview release form. 9
Authorization for Photographs/Interview Addendum to SYS-ADM-018 I hereby authorize Lakeview Health Foundation/Lakeview Health System to:! Take photographs, video and/or interview (your name) for the purpose of: Lakeview Health Foundation Scholarship recipient publicity. I agree to hold Lakeview Health and its member organizations harmless from any liability that may occur as a result of said photographs/interview. I understand that I may revoke this authorization up until a reasonable time before my photo or interview is used. Revoking requires notifying Lakeview Health in writing. Signature Date Print name of signatory Witness Signature Date: Print name of Witness PRINT NAME ADDRESS CITY/STATE/ZIP DAYTIME PHONE EMAIL Consent forms on which Community Relations obtains signatures will be retained by Community Relations for five years. All other signed consents for video/digital recording and photographs will be retained in scholarship recipient s application file @ Lakeview Health Foundation. 10