2021 Foundation Scholarship Application Form QUALIFICATIONS Applicant must have been employed by a GHCA member provider (SNF, ALF, SOURCE) for one year Applicant must be recommended by the Administrator/Executive Director and Director of Nursing/Clinical Supervisor Commit to part-time or full-time employment while attending school; and, Remain employed in the GHCA member provider setting of their choice for one year post-graduation The deadline to submit the Georgia Health Care Association Education & Research Foundation Scholarship Application Form is May 24, 2021. Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Address 1 Question Title * 4. Address 2 Question Title * 5. City Question Title * 6. State Question Title * 7. Zip Question Title * 8. Phone Question Title * 9. Email Question Title * 10. Name of GHCA member SNF/ALF/SOURCE agency where you work Question Title * 11. Work Address Line 1 Question Title * 12. Work Address Line 2 Question Title * 13. City Question Title * 14. State Question Title * 15. Zip Question Title * 16. Work Phone Question Title * 17. Administrator First Name Question Title * 18. Administrator Last Name Question Title * 19. Administrator Email Question Title * 20. Dates of Employment From To Question Title * 21. College/Institution where you have been accepted Question Title * 22. Student ID # Question Title * 23. City of college/institution where you have been accepted Question Title * 24. Contact Information for above college/institution Question Title * 25. Name of major/degree program Question Title * 26. Date by which you expect to complete your studies IMPORTANT - Please attach the following additional information to your application form: Question Title * 27. A letter of explanation from the applicant outlining why he/she is interested in a career in Nursing (limit: one page). PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File A letter of explanation from the applicant outlining why he/she is interested in a career in Nursing (limit: one page). Question Title * 28. Written recommendation from the facility Administrator and the Director of Nursing. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Written recommendation from the facility Administrator and the Director of Nursing. Question Title * 29. A copy of the letter of acceptance from the accredited school where the applicant has been accepted or is enrolled (For nursing, the letter must indicate that the applicant is enrolled in or has been accepted into a LPN or RN program). PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File A copy of the letter of acceptance from the accredited school where the applicant has been accepted or is enrolled (For nursing, the letter must indicate that the applicant is enrolled in or has been accepted into a LPN or RN program). Question Title * 30. Any other documents that you feel would enhance your application. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Any other documents that you feel would enhance your application. Question Title * 31. Additional Document 2 PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Additional Document 2 Question Title * 32. Additional Document 3 PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Additional Document 3 Question Title * 33. Additional Document 4 PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Additional Document 4 PLEASE NOTE: If you have additional files you would like to submit beyond the ones attached to this application form, please email those files to Pam Clayton at pclayton@ghca.info Question Title * 34. STATEMENT OF ACCURACYI hereby verify that the information I am submitting is true to the best of my knowledge and I agree to submit proof of the same, should such information be requested. I further agree that any scholarship funds received by me from the Foundation will be used by me to further my education in Long Term Care. Name Date Done