HP CO Healthcare Scholarship | Harper County Health Foundation

First name

Last name

Email

Address

Position and Location of Employment

Name of providing educational institution or organization applying to:

Have you or will you fill out a FAFSA request?

Yes

No

Unsure

If pursuing a higher level certification of RN or PA, etc. have you applied for the National Health Service Corp or the Nurse Corp? (Note - non-PHC employees are ineligible. If you're unaware of this option, PHC employees, please contact Kim Barwick.)

Yes

No, I don't qualify

PHC Employees: Have you applied for the Patterson Health Center employee assistance scholarship?

Yes

No

Not applicable

Total Funds requested for the entire program / degree / certification:

Please describe how the education that is gained from this will impact your present or future job in Harper County.

What is your expected timeline for your classes and completion of your degree?

Are there any other grants or scholarships you've applied for or have been awarded? If so, please provide details.

If applicable, what is your GPA of your current program or last degree?

When would the payment be needed and who is the check to go to (i.e. each semester or one lump sum?) Please include an address and your Student ID number.

Please attach or email any documentation of the cost of the program from your institution. (Email lwilsonhcohf@gmail.com if files cannot be uploaded)

Provide a letter of recommendation.

Provide a letter from your current employer stating assurance of future employment after program completion (dependent on site circumstances.)

Check the boxes if you agree to these terms. Please read carefully.

To receive funding, you must commit to working in the healthcare field in Harper County for a minimum of 3 years following graduation or completion of certification.

If Applicant leaves the Harper County healthcare community before the completion of 3 year commitment, Applicant will refund the Foundation a prorated amount of the total based on months in employment.

If Applicant fails or does not complete the course or program, the applicant will reimburse the foundation for 100% of the award.

An agreement with HCHF will need to be signed to this effect before funding is given.

Applicant is asked to report progress per semester or completion of certification program to Foundation. Pictures are appreciated!

Applicant must notify the Patterson Health Center CEO or other Harper County healthcare employer to approve the application and submit a letter of employment to the foundation.

Harper County Healthcare Workers Scholarship Application

Check the boxes if you agree to these terms. Please read carefully.

Harper County Healthcare Workers
Scholarship Application