Foundation Scholarship Application

Application can not be saved once begun.

Name (Last, First, MI):
Colleague ID:
Address:
City:
State:
Zip code:
Phone number:	( ) - Second three digits Last four digits
Marital status:
Number of dependent children:
Name of school you are attending/have been accepted to attend:
Degree you are seeking:
Number of semesters already completed:
Current GPA:
Primary hospital:
Department(s) employed in:
Position:
Total years of employment at HSHS:
Employment status:	Full time Part time
Director/Manager’s name:
What is your total annual household income:	(Household income includes the gross income of each person, 15 years or older, living in the home.)
Have you received a scholarship through this program in the past:	Yes No
If yes, please provide year(s) received:
What is the total tuition cost for one academic year:
What are the total student fees to be paid in addition to tuition:
Please specify:
Approximately how much will you have to spend for books for the academic year:
What other expenses do you anticipate as part of your education this year:
Please specify:
Total cost you are requesting:
“I am proud to work at HSHS because…”:
“My career goals are…”:
“I need financial assistance because…”:
“My education will benefit patients by...”:
List extracurricular or community activities, honors, and awards; offices held; etc.:
Current academic transcripts:
I understanding that no funds will be released until a 'Thank You' is received:
Security code: