Application Form

First Name

Last Name

Email

Date of Birth

Permanent Street Address

City

State

Zip Code

County

Phone Number

Current Grade Point Average (GPA)

What school will you attend this Spring/Fall?

Will you be attending ...

full-time part-time

Are you employed?

Yes No

Employer Name

Employer Address

Employer City, State, Zip

Are you receiving tuition assistance/reimbursement from your employer?

Yes No

If you are receiving reimbursement, how much?

Are you interested in contract required scholarship opportunities through HSHS Illinois hospitals?

Yes No

Provide one professional reference

Reference email

Have you completed the Free Application for Federal Student Aid (FAFSA)?

Yes No

Are you receiving any federal or state financial aid (as of today)?

Yes No

Why are you applying for this scholarship?

Please use 500 words or less to explain why you are applying for a scholarship. Please include specific areas of health care that interest you. Scholarship essays may be shared with donors and/or the public.*

Consent for Release

I hereby consent to the release of any information in connection with the foregoing that in the sole judgment of the Viola Thompson Scholarship Selection Committee may be of assistance in evaluating my scholarship application. I hereby waive any confidentiality with respect to such information in so far as the Viola Thompson Scholarship Selection Committee is concerned, since it is my understanding that the information will be used solely for the evaluation of my applications for scholarship and for no other purpose.

Do you understand these conditions and are you willing to accept the scholarship with these conditions?

Yes No

The Viola N. Thompson Scholarship Fund was established to recruit, train, educate or retain any physicians, nurse practitioners, physician's assistances, or other licensed medical or healthcare providers, to provide medical services to the Bond County, Illinois.

Upload Transcript

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Upload Proof of Enrollment

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Upload Letter of Recommendation

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Viola N. Thompson Scholarship Application