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.

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* 1. First Name

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* 2. Last Name

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* 3. Address 1

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* 4. Address 2

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* 5. City

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* 6. State

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* 7. Zip

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* 8. Phone

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* 9. Email

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* 10. Name of GHCA member SNF/ALF/SOURCE agency where you work

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* 11. Work Address Line 1

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* 12. Work Address Line 2

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* 13. City

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* 14. State

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* 15. Zip

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* 16. Work Phone

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* 17. Administrator First Name

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* 18. Administrator Last Name

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* 19. Administrator Email

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* 20. Dates of Employment

From

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* 21. College/Institution where you have been accepted

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* 22. Student ID #

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* 23. City of college/institution where you have been accepted

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* 24. Contact Information for above college/institution

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* 25. Name of major/degree program

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