MHACENTER FOR EDUCATION

MISSOURI HOSPITAL EMPLOYEE SCHOLARSHIP

Application Form

Must bepostmarked by Friday, September 30, 2016 for final funding opportunity.

NOTE: There are three sections in this application: Section 1 must be completed by the applicant;Section 2 must be completed by the applicant’s manager/supervisor; Section 3 must be completed by the human resources director and signed by the chief executive officer. To be eligible for final round of funding, applications must be submitted through the hospital’s human resources director and must be postmarked on or before Friday, September 30, 2016.

Please type or print.

Section 1A: HOSPITAL INFORMATION

Hospital Name / Hospital Location (City)
Name of Hospital System (if applicable)

Section 1B: PROGRAM INFORMATION

To be eligible for this scholarship, please indicate your Course of Study and Level of Study below.
COURSE OF STUDY LEVEL OF STUDY
______Certificate
Bachelor degree
ESTIMATED DATE OF COMPLETION Master’s degree
______Doctorate
Other (please describe below)
AMOUNT REQUESTED
______

ENROLLMENT

IMPORTANT: If already accepted into a program, please attach proof of acceptance or enrollment and complete the information below. If not yet accepted, please complete the information below as best as possible.

Name of Institution and Program You Will Attend
/ Address
Name of Contact Person / Title of Contact Person / Telephone
( )

Section 1C: APPLICANT INFORMATION

Name (Last, First, Middle Initial) / Social Security Number
Maiden Name/Other Names Used / Telephone
( )
Current Title/Position at Hospital
Current Mailing Address (Street) / City
State
/ ZIP / E-mail Address
Permanent Mailing Address (Street) if different from above / Telephone
( )
City
/ State / ZIP

All information is confidential and for program purposes only.
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Section 1D: JUSTIFICATION
Please describe why you are pursuing this educational program.
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Section 1E: APPLICANT CERTIFICATION
I certify the information contained in this application is true, complete and correct to the best of my knowledge and that all reimbursements requested will be for tuition expenses related to the program in which I am entering or enrolled. I hereby authorize the release of personal, scholastic and financial information related to my educational status to the MHA Center for Educationfrom any academic institution I have attended in the past and any academic institution in which I am enrolled or may be enrolled as a future student.
Signature of Applicant / Date

SUBMISSION INSTRUCTIONS

Once completed, submit the original application and proof of enrollment or acceptance (if available) to your manager/supervisor. The manager/supervisor should complete page 3 of the application and forward to the hospital’s human resources director. Questions about the program should be directed to the Jean Klindt at the Missouri Hospital Association at 573/8933700.

ATTENTION HOSPITAL EMPLOYEE:
Upon completion, route application and proof of acceptance/enrollment (if available) to manager/supervisor. Be certain to complete Section 2A of the Manager/Supervisor Recommendation and Section 3A of the Human Resources Approval Form.

All information is confidential and for program purposes only.
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MHACENTER FOR EDUCATION

MISSOURI HOSPITAL EMPLOYEE SCHOLARSHIP

Application Form

Must be postmarked by Friday, September 30, 2016

Manager/Supervisor Recommendation Form

INSTRUCTIONS TO APPLICANT
Once you have completed pages 1 and 2, fill out Section 2A below and Section 3A on the Human Resources Approval Form. Provide the entire four-page application and proof of acceptance or enrollment (if available) to your manager/supervisorto continue the application process.
Section 2A: TO BE COMPLETED BY APPLICANT
Printed Applicant Name / Job Title
Signature of Applicant / Date
INSTRUCTIONS TO MANAGER/SUPERVISOR
Please complete Section 2B below and forward to the Human Resources Director to complete the submission process.
Note: Failure to complete all sections of the application may deem the application ineligible.
Section 2B: TO BE COMPLETED BY MANAGER/SUPERVISOR
Printed Name of Manager/Supervisor

Is the applicant a current employee?

 YesNo

Does the applicant exhibit acceptable performance?

 YesNo

Do you recommend the applicant for the MissouriHospital Employee Scholarship?

 YesNo
Please share any additional comments.
______
______
______
Signature of Manager/Supervisor / Date

MHA CENTER FOR EDUCATION

MISSOURI HOSPITAL EMPLOYEE SCHOLARSHIP

Application Form

Submission Deadline – Friday, September 30, 2016

Human ResourcesApproval Form

Section 3A: TO BE COMPLETED BY APPLICANT
Printed Applicant Name / Job Title
Signature of Applicant / Date
INSTRUCTIONS TO HUMAN RESOURCES
Please review the application and Manager/Supervisor Recommendation Form. Once reviewed, please indicate if you approve or do not approve this application.
Note: Failure to complete all sections of the application may deem the application ineligible.
Section 3B: CHIEF EXECUTIVE OFFICER AND HUMAN RESOURCES APPROVAL
Check one.
I approve this application for a Missouri Hospital Employee Scholarship.
I do not approve this application for a Missouri Hospital Employee Scholarship.
What is the amount recommended to be awarded to employee? (Please note: A maximum of $10,000 in scholarship funds will be available to each member hospital. Complete excel file attached.) / $
Printed Name of Chief Executive Officer / Title
Signature of Chief Executive Officer / Date
Printed Name of Human Resources Representative / Title
Signature of Human Resources Representative / Date

SUBMISSION INSTRUCTIONS TO HUMAN RESOURCES:

1. In the Applicant Tracking SpreadsheetExcel file provided, please complete the requested information for each applicant and email the file to .

2. Upon completion of the paper application form(s), staple the four-page application along with the employee’s proof of acceptance or enrollment (if available). Page one of the application should be at the top of the stapled packet.

3. Mail applications, postmarked by Friday, September 30, 2016, toMissouri Hospital Employee Scholarship, MHA Center for Education, P.O. Box 60, Jefferson City, MO 65102-0060

All information is confidential and for program purposes only.
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