Joann Burns Memorial Scholarship Application

for Health and Science Education

This scholarship is available to any student accepted into or enrolled in a full-time program leading to a career in the Health and/or Science field. Priority will be given to individuals who have:

  • Lost a parent, sibling, aunt, uncle or grandparent to cancer
  • Attended a Klamath basin high school, public or private
  • Volunteered 50 hours of community service and/or show proof of hours spent aiding an individual battling cancer

This scholarship may be used for any school-related expenses such as tuition, books, lab fees, etc. The awarding committee will consider only applicants with a cumulative G.P.A. of at least 2.75, with preference being given to 3.0 and above.

Copies of this application can be downloaded by going to the following website: skylakes.org/foundation/scholarships/

  1. Instructions: Mail or deliver the following items by 12:00 PM (noon) Friday, May 25th, 2018, to:

SkyLakesMedicalCenter Foundation

2865 Daggett Avenue

Klamath Falls, Oregon97601

  1. This completed application form.
  1. An official transcript of your high school/college record to date.
  1. A 300-500 word essay about yourself, including hobbies, plans and aspirations, factors which have favorably or adversely influenced your life, reason for pursuing a degree in a Health or Science field, and any other information about yourself which you think pertinent. Please type or handwrite legibly.
  1. If applicable, a 2-3 paragraph explanation of your relationship and involvement with an individual who has or had cancer.
  1. Three completed recommendation forms (attached) from individuals who know you well. These may include a business man or woman, your minister, a counselor, a teacher/ professor under whom you have taken courses this year, a coach, or present employer. We ask that these recommendations do not come from a relative or friend. The recommendations should be in sealed envelopes so that they may be confidential.
  1. Mail all items in a single packet.
  1. Name of Applicant

LastFirstMiddle

  1. Date of Birth

MonthDayYear

  1. Applicant’s CurrentSchool

School Address

  1. Current or Intended Major ______
  1. Applicant’s Home Address
  1. Applicant’s Telephone Number
  1. Name of Father/Guardian

Occupation

  1. Name of Mother/Guardian

Occupation

  1. Number of siblings in family older than you?Younger than you?
  1. Name of Spouse (If Applicable) ______

Occupation______

  1. Number of Children (If Applicable) ______
  1. ListHigh Schools and Colleges you have attended:

School or CollegeLocationDates Attended

______

______

  1. Name and address of the school you have been accepted to attend (if different from above):

______

______

  1. How involved are you within your school and/or your community? Please list any special clubs, organizations, projects, sports teams, or personal volunteering that you have been a part of during the past two years. Include any important information regarding positions held or approximate amount of time/hours involved. (Use additional pages if needed)

______

______

______

______

  1. What special honors, prizes or scholarships have you received for academic or other work during your last two years in high school and/or college? (Use additional pages if needed)

______

______

______

______

  1. Describe your work experience (part-time, full-time, and vacation periods). List employers and duration of employment (use additional pages if needed).

EmployerJob Title/DescriptionDates Worked

______

______

______

  1. List approximate dollar amounts for your college expenses for current year and for next year to be supplied by:

Current Year Next Year

  1. Parents/Spouse______
  1. Scholarships______
  1. Loans______
  1. Savings during Vacations______
  1. Earnings during school______
  1. Other sources (specify)______
  1. For what other scholarships are you applying?

______

______

______

  1. Estimate total amount of additional cash needed for next year in college.

______

  1. Other comments:

______

______

______

  1. Date
  1. Signature of Applicant

*By signing you agree that all information is true and up to date. If found otherwise you will become ineligible.

Joann Burns Memorial Scholarship

Reference Form

Thank you for taking the time to complete this Reference Form for the Joann Burns Memorial Scholarship review committee. The student who asked you to fill in this form is applying for a scholarship to pursue studies toward a career in the health and science industry. Along with a strong academic background, the committee looks for students with skills that will enable him or her to work well with patients and with fellow healthcare workers.

Please answer the following using this scoring scale:

1=This person demonstrates very little of this characteristic and will need significant development.

2=This person has some of this characteristic but lacks depth in many of the criteria.

3=This person demonstrates a slightly less than average to average amount of this characteristic.

4=This person demonstrates an average to slightly better than average amount of this characteristic.

5=This person has significant strength in this characteristic.

6=This person demonstrates an exceptional level in this characteristic and is a role model.

Student’s Name: ______

Attitude:

Is courteous and cordial to fellow students, teachers, customers, family. ____

Demonstrates a positive attitude. _____

Welcomes and accepts personal accountability for actions and behaviors. _____

Communication/Etiquette:

Smiles, listens, makes eye contact and treats everyone with dignity and respect. _____

Communicates requests, suggestions in a positive, non-threatening manner. _____

Service:

Willing and eager to assist at all times. _____

Personal:

Maintains the self-confidence and self-esteem of others. _____

Maintains a good relationship with others. _____

Takes the initiative to make things a little better. _____

Please answer the following questions:

  1. What are this student’s strengths as you see them to pursue a career in the health industry?
  1. In what areas do you think a career in the health industry will help this student grow and develop?

Print Name of Person Completing this Form: ______

Signature of Person Completing this Form: ______

Relationship to Applicant: ______

Joann Burns Memorial Scholarship

Reference Form

Thank you for taking the time to complete this Reference Form for the Joann Burns Memorial Scholarship review committee. The student who asked you to fill in this form is applying for a scholarship to pursue studies toward a career in the health and science industry. Along with a strong academic background, the committee looks for students with skills that will enable him or her to work well with patients and with fellow healthcare workers.

Please answer the following using this scoring scale:

1=This person demonstrates very little of this characteristic and will need significant development.

2=This person has some of this characteristic but lacks depth in many of the criteria.

3=This person demonstrates a slightly less than average to average amount of this characteristic.

4=This person demonstrates an average to slightly better than average amount of this characteristic.

5=This person has significant strength in this characteristic.

6=This person demonstrates an exceptional level in this characteristic and is a role model.

Student’s Name: ______

Attitude:

Is courteous and cordial to fellow students, teachers, customers, family. ____

Demonstrates a positive attitude. _____

Welcomes and accepts personal accountability for actions and behaviors. _____

Communication/Etiquette:

Smiles, listens, makes eye contact and treats everyone with dignity and respect. _____

Communicates requests, suggestions in a positive, non-threatening manner. _____

Service:

Willing and eager to assist at all times. _____

Personal:

Maintains the self-confidence and self-esteem of others. _____

Maintains a good relationship with others. _____

Takes the initiative to make things a little better. _____

Please answer the following questions:

  1. What are this student’s strengths as you see them to pursue a career in the health industry?
  1. In what areas do you think a career in the health industry will help this student grow and develop?

Print Name of Person Completing this Form: ______

Signature of Person Completing this Form: ______

Relationship to Applicant: ______

Joann Burns Memorial Scholarship

Reference Form

Thank you for taking the time to complete this Reference Form for the Joann Burns Memorial Scholarship review committee. The student who asked you to fill in this form is applying for a scholarship to pursue studies toward a career in the health and science industry. Along with a strong academic background, the committee looks for students with skills that will enable him or her to work well with patients and with fellow healthcare workers.

Please answer the following using this scoring scale:

1=This person demonstrates very little of this characteristic and will need significant development.

2=This person has some of this characteristic but lacks depth in many of the criteria.

3=This person demonstrates a slightly less than average to average amount of this characteristic.

4=This person demonstrates an average to slightly better than average amount of this characteristic.

5=This person has significant strength in this characteristic.

6=This person demonstrates an exceptional level in this characteristic and is a role model.

Student’s Name: ______

Attitude:

Is courteous and cordial to fellow students, teachers, customers, family. ____

Demonstrates a positive attitude. _____

Welcomes and accepts personal accountability for actions and behaviors. _____

Communication/Etiquette:

Smiles, listens, makes eye contact and treats everyone with dignity and respect. _____

Communicates requests, suggestions in a positive, non-threatening manner. _____

Service:

Willing and eager to assist at all times. _____

Personal:

Maintains the self-confidence and self-esteem of others. _____

Maintains a good relationship with others. _____

Takes the initiative to make things a little better. _____

Please answer the following questions:

  1. What are this student’s strengths as you see them to pursue a career in the health industry?
  1. In what areas do you think a career in the health industry will help this student grow and develop?

Print Name of Person Completing this Form: ______

Signature of Person Completing this Form: ______

Relationship to Applicant: ______

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