Dr Ralph Waldo Stearns, Sr Scholarship
Dr Ralph Waldo Stearns, Sr.,
Nurse’s Education Fund Scholarship Application
This scholarship is restricted to nursing education in an amount not to exceed the tuition assessed by Oregon State System of Higher Education Institutions and may be used at any accredited school of nursing in the State of Oregon. The awarding committee will consider only applicants with a cumulative G.P.A. of at least 2.00 or equivalent. Applicants must have completed high school and show satisfactory course work in some of the following: physics, chemistry, math or general science. Priority will be given to graduates of a Klamath County or Klamath Basin high school in any school, public or private, within the County or Basin.
Copies of this application blank may be procured by sending a stamped self-addressed envelope to:
Sky Lakes Medical Center Foundation
2865 Daggett Avenue
Klamath Falls, Oregon 97601
A. Instructions: Mail or deliver the following items by midnight Friday, February 21, 2014, to:
Sky Lakes Medical Center Foundation
2865 Daggett Avenue
Klamath Falls, Oregon 97601
1. This completed application form.
2. An official transcript of your school or college record to date.
3. A 300-500 word essay about yourself, including hobbies, plans and aspirations, factors which have favorably or adversely influenced your life, health, reason for desiring to attend the school or college you have chosen, and any other information about yourself which you think pertinent. Please type if possible.
B. Three letters of recommendation from individuals who know you well. These may include a businessman or businesswoman, minister, professor under whom you have taken courses this year, or present employer. Please ask each of them also to fill in a copy of the reference form included with this application.
C. Mail all items in a single packet. The letters of recommendation should be in sealed envelopes so that they may be confidential.
1. Name of Applicant
Last First Middle
2. Date of Birth
Month Year
3. If Married, Spouse’s Name
Occupation
If applicable, Children’s Names and Ages
4. Applicant’s Current School
School Address
5. Applicant’s Home Address
6. Applicant’s Telephone Number
7. List High Schools and Colleges you have attended:
School or College Location Dates Attended
8. Name of School or College you plan to attend next year
9. If you are transferring from your present school or college, please state reason
10. From which school or college do you plan to graduate?
11. List special honors, prizes or scholarships you have received for academic work during your last two years in high school and in college (use additional pages if needed):
12. Describe your work experience (part-time, full-time and vacation periods.) List employers and duration of employment (use additional pages if needed):
Employer Job Title/Description Dates Worked
13. Why are you interested in becoming a nurse? (Please use additional pages if needed.)
14. List activities in which you have taken part during the last two years of high school or in college. Mention any special recognition received or offices held. Use additional pages if needed.
High School
College
Community or Church Organizations
15. 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
2. Scholarships
3. Loans
4. Savings during Vacations
5. Earnings during school
6. Other sources (specify)
16. For what other scholarships are you applying?
17. Estimate total amount of additional cash needed for next year in college.
18. Other comments
19. Date
20. Signature of Applicant
Dr Ralph Waldo Stearns, Sr.,
Nurse’s Education Fund Scholarship
Reference Form
Thank you for taking the time to complete this Reference Form for the Dr Ralph Waldo Stearns, Sr. Nurse’s Education Fund 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 nursing. 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: (Use additional space if needed.)
1. What are this student’s strengths as you see them to pursue a career in nursing?
2. In what areas do you think a career in nursing will help this student grow and develop?
Signature of Person Filling in Form: ______
Print Name: ______
Relationship to Applicant: ______
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