Medical Excellence

Transcript

1 APPLICATION FOR MEDICAL EXCELLENCE SCHOLARSHIP Citizens Memorial Hospital Citizens Memorial Healthcare Foundation ● ● fax 417.328.6548 ● 1500 North Oakland Ave phone 417.328.6426 ● Bolivar, Missouri 65613 www.citizensmemorial.com Thank you for your interest in a scholarship from the Medical Excellence Fund. Your APPLICANT PLEASE READ: application will receive consideration without regard to race, sex, national origin, age, physical or mental impairment or veteran status. PLEASE NOTE: Any application that is turned in incomplete will not be accepted. For your convenience, there is a check list on page three of this application. Please follow all directions while completing this application and answer all questions as carefully, completely and honestly as possible. Name Address State Zip Code City Phone County Social Security Number Email Foundation Have you ever been employed by Citizens Memorial Hospital, Citizens Memorial Healthcare No Yes or Riverside Management and Rehabilitation? Dates of Employment: From: To: If yes, where? Do you have any relative(s) working for this organization? No Yes If yes, please list their name(s), department, facility, and relationship: Do you now have, or have you ever had, an illness, injury or chronic condition that would now prevent you from working in a Yes No health care facility? If yes, please describe (include the name and address of your attending physician). Have you ever had (in Missouri or any other state) a conviction or plea of guilty to a misdemeanor or felony charge which would include any suspended imposition of sentence, and suspend execution of sentence or any period of probation or parole? Yes No If yes, please list the conviction(s), showing the offense and date. (The listing of conviction(s) will not necessarily disqualify you from consideration for scholarship application.) Are you currently or have you ever been listed on a Missouri or other state's disqualification list? No Yes If yes, please explain:

2 EMPLOYMENT HISTORY Please list your most current position first and work back. POSTIONS HELD /DUTIES OF REASON FOR LEAVINGMUST BE DATES OF EMPLOYMENT COMPANY NAME /ADDRESS COMPLETED) YOUR JOB FROM: TO: NAME APPEARING ON FORMER May we contact for a EMPLOYER’S RECORDS reference? Yes / No Telephone Number SUPERVISOR’S NAME REASON FOR LEAVINGMUST BE POSTIONS HELD /DUTIES OF DATES OF EMPLOYMENT COMPANY NAME /ADDRESS COMPLETED) YOUR JOB FROM: TO: NAME APPEARING ON FORMER May we contact for a EMPLOYER’S RECORDS reference? Yes / No Telephone Number SUPERVISOR’S NAME REASON FOR LEAVINGMUST BE POSTIONS HELD /DUTIES OF COMPANY NAME /ADDRESS DATES OF EMPLOYMENT COMPLETED) YOUR JOB : FROM TO: NAME APPEARING ON FORMER May we contact for a EMPLOYER’S RECORDS reference? Yes / No Telephone Number SUPERVISOR’S NAME EDUCATION IMPORTANT: Please submit an original official transcript for each secondary and post-secondary academic institution attended. Note: If you have a GED, include the original transcript with signature. Transcripts must be received with the application, before the February 27th deadline. College 4 4 12 8 6 7 2 9 10 11 3 1 GED 1 3 2 5 Check the highest grade completed. High School Attended and Location Graduation Date College/University Attended Dates Attended Graduation Date Degree Earned Hours Hours Graduation Date Degree Earned College/University Attended Dates Attended If additional space is needed, please attach a separate sheet ENROLLMENT This section is to be completed and signed by a representative of the health profession program of acceptance. Address Tuition – Semester/Year Name of Institution Academic Fees – Semester/Year $ Term $ Term Name of Contact Person Title Telephone of Contact Person Academic Year Applied For Projected Graduation Date Program Start Date Student’s Current Year in the Program I certify that the applicant is enrolled and in good standing or has been accepted for enrollment. Additional information deemed necessary will be provided by Citizens Memorial Healthcare upon request. Signature of School Representative School or Notary Stamp Title Date

3 EDUCATIONAL OBJECTIVE What certification or licensure will you be eligible for upon completion of this program? How much assistance (annually) do you request? How did you become interested in our Medical Excellence Scholarship? Why do you seek a scholarship from the Medical Excellence Scholarship Fund? In what health care setting do you wish to provide care upon completion of your chosen program? (Hospital, community, ambulatory care, long-term care, etc.) Please state any other information that you believe would be helpful to the Scholarship Selection Committee (include extracurricular activities, hobbies, awards, honors, volunteer activities, etc). PERSONAL STATEMENT Please include, in your application, a personal statement describing your commitment to provide healthcare in Missouri. This statement should not exceed one single-spaced typewritten page. The personal statement should reflect your personal reason(s) for choosing health care as a profession, including your professional goals. Enclose the original personal statement and one copy with the completed application. REFERENCES You will also need to have three references completed to turn in with your application. The back page is an example of what we would like for them to fill out. Please make copies of this back page and give to the references of your choice. They will need to submit the form to you in a sealed envelope, with the envelope flap signed by the reference. You will need to submit these references with your application to be considered for this scholarship. APPLICATION CHECKLIST COMPLETE COMPONENTS NOTE: All documents submitted must be original. Faxed or e-mailed documents will not be accepted. All sections of the application completed • enrollment section completed and signed by a school representative • application signed and dated Personal statement enclosed reflecting personal reason(s) for choosing health care as a profession Three reference forms enclosed in sealed envelopes, with the envelope flap signed by the reference Original high school transcript or GED enclosed Original post-secondary transcript(s) enclosed It is the applicant’s responsibility to ensure all components of the Medical Excellence Scholarship Application are complete. This checklist is provided to assist the applicant. Failure to submit a complete application may result in the application being deemed ineligible or in a reduction of points when scored. By signing in the boxes below, you are stating that: I certify that I have read the foregoing application, which I understand the questions, which the answers given are true and authorized investigation of all statements contained in this application. I understand that a materially false answer will disqualify me from consideration for a scholarship from the Medical Excellence Fund. I release Citizens Memorial Healthcare, its agents and employees from any liability resulting from such investigation, and I authorize investigation of all statements contained in this application. I also understand that I will be obligated to work within the Citizens Memorial Healthcare organization upon graduation. Printed Name of Applicant Applicant Signature Date

4 Name of Applicant SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Please complete this form as accurate and honestly as possible. After you have completed this form, place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return this envelope to the applicant. th deadline. The applicant will return the sealed envelope with his or her application by the February 28 How well do you know this applicant? Minimally Fairly Well Very Well Unknown How long have you known the applicant? Identify the association you have had with the applicant. Check all that Instructor Academic Advisor Other Employer/Supervisor Community Organization Please rate the applicant’s achievement and potential by entering an “X” in the appropriate spaces below. Above Not Able to Below Average Skill Average Exceptional Respond Average Decision Making Ability Organizational skills Communication skills: Written/Oral Adaptability to stress Positive attitude Integrity Interpersonal sensitivity Leadership ability In addition to the ratings, please give your evaluation of the applicant. It is important that you complete this section. You may want to indicate your perceptions of the applicant’s strengths and limitations. My recommendation is: Highly recommend Recommend Do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number

Related documents

AffordableExcellencePDF

AffordableExcellencePDF

HASE LTINE This is the story of the Singapore healthcare system: how it works, how it is financed, its history, where it is going, and AFFORDABLE EXC what lessons it may hold for national health syste...

More info »
Social Studies United States History Teacher Notes

Social Studies United States History Teacher Notes

United States History Teacher Notes for the Georgia Standards of Excellence in Social Studies The Teacher Notes were developed to help teachers understand the depth and breadth of the standards. In so...

More info »
Building Excellent Schools Today (BEST) Annual Report

Building Excellent Schools Today (BEST) Annual Report

Building Excellent Schools Today (BEST) Annual Report Submitted to: Senate Education Committee Senate Finance Committee House Education Committee House Finance Committee Capital Development Committee ...

More info »
20180430 Through Growth to Achievement Text

20180430 Through Growth to Achievement Text

Through Growth to Achievement Report of the Review to Achieve Educational Excellence in Australian Schools March 2018 Review Panel Mr David Gonski AC Mr Terrey Arcus AM Dr Ken Boston AO Ms Valerie Gou...

More info »
Microsoft Word   K 12  VISUAL ART GSE 6 15 17.docx

Microsoft Word K 12 VISUAL ART GSE 6 15 17.docx

Visual Art Georgia Standards of Excellence (GSE) – Kindergarten Grade 12

More info »
God's Passion His.40079.int.qxd

God's Passion His.40079.int.qxd

S P ASSION FOR G OD ’ IS G LORY H Living the Vision of Jonathan Edwards With the Complete Text of The End for Which God Created the World OHN P IPER J CROSSWAY BOOKS A DIVISION OF GO OD NEWS PUBLISHER...

More info »
CDIR 2018 07 27

CDIR 2018 07 27

S. Pub. 115-7 2017-2018 Official Congressional Directory 115th Congress Convened January 3, 2017 JOINT COMMITTEE ON PRINTING UNITED STATES CONGRESS UNITED STATES GOVERNMENT PUBLISHING OFFICE WASHINGTO...

More info »
G:\COMP\PHSA\PHSA.bel

G:\COMP\PHSA\PHSA.bel

G:\COMP\PHSA\PHSA-MERGED.XML PUBLIC HEALTH SERVICE ACT [As Amended Through P.L. 115–408, Enacted December 31, 2018] References in brackets ¿ ø¿ ø are to title 42, United States Code TITLE I—SHORT TITL...

More info »
School, Family, and Community Partnerships: Your Handbook for Action. Second Edition.

School, Family, and Community Partnerships: Your Handbook for Action. Second Edition.

DOCUMENT RESUME ED 467 082 PS 030 545 Epstein, Joyce L.; Sanders, Mavis S.; Beth Simon, G.; AUTHOR Natalie Rodriguez; Van Jansorn, Salinas, Karen Clark; Voorhis, Frances L. Handbook for School, Family...

More info »
Visits and Meetings in the NISP Student Guide

Visits and Meetings in the NISP Student Guide

Visits and Meetings in the NISP Student Guide September 2017 Center for Development of Security Excellence

More info »
Archived Information: For Each and Every Child: A Strategy for Education Equity and Excellence    February 2013 (PDF)

Archived Information: For Each and Every Child: A Strategy for Education Equity and Excellence February 2013 (PDF)

The Equity and Excellence Commission A Report to the Secretary A STRATEGY FOR EDUCATION EQUITY AND EXCELLENCE A STRATEGY FOR EDUCATION EQUITY AND EXCELLENCE 1

More info »
AndersBehringBreivikManifesto

AndersBehringBreivikManifesto

2011 , London – By Andrew Berwick

More info »
cat51a metric

cat51a metric

Wheaton Facility Aabybro Facility Springeld Facility P.O. Box 7900 Mølhavevej 2 1801 Business Park Drive Wheaton, Illinois DK 9440 Aabybro Springeld, Illinois 60187-7901 USA Denmark 62703 USA www.te...

More info »
Tapping the Potential: Retaining and Developing High Quality New Teachers

Tapping the Potential: Retaining and Developing High Quality New Teachers

Every Child A Graduate Tapping the Potential Retaining and Developing High-Quality New Teachers

More info »
Monthly Energy Review – April 2019

Monthly Energy Review – April 2019

DOE/EIA ‐ 0035( 2019/4 ) April 2019 Monthly Energy Review www.eia.gov/mer

More info »
Microsoft Word   01 Front page.doc

Microsoft Word 01 Front page.doc

Final Reports of Technical Review Of Costing Tools Commissioned by an Inter-agency Steering Committee and the Partnership for Maternal, Newborn and Child Health This package contains the final reports...

More info »
The Qualities of Quality: Understanding Excellence in Arts Education

The Qualities of Quality: Understanding Excellence in Arts Education

Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q ...

More info »
Specify Help

Specify Help

This document is a print-formatted version of the information contained in the context-sensitve help system in Specify 6.5. Post Mortem, We Sort 'Em Specify Software Project Contact Information The Sp...

More info »
Accountability and the Every Student Succeeds Act (ESSA)

Accountability and the Every Student Succeeds Act (ESSA)

Every Student Succeeds Act (ESSA) Public Update July 11, 2018

More info »