PETER H. AND NELLIE T. JORGENSEN SCHOLARSHIP PROGRAM
APPLICATION FOR FAMILY HEALTH CARE SCHOLARSHIP

PERSONAL INFORMATION                                                                     DATE_____________________

1. Legal name_____________________________________________________________________
                         (Last)                                (First)                        (Middle)                               (Maiden)

2. Social Security No.________-_____-_________

3. Permanent home address:                                               4. Campus Address:

______________________________                          ______________________________    

______________________________                          ______________________________

Telephone(___)________________                              Telephone(___)________________

5. Are you a citizen of the United States? (Yes)_______ (No)_______

6. Marital status: Married______ Single______ Other______

7. Name of Spouse_________________________________________________________________
                                      (Last)                              (First)                               (Middle)                       (Maiden)

8. No. of dependent children (if any)_______
Child support obligations $____________ per___________.

9. Will spouse (or prospective spouse) be a student? (Yes)_____(No)_____ Where______________________________ Apply for aid? (Yes)_____(No)____

10. Name of parents or guardians____________________________________________
Address_______________________________________________________________
Occupation(s)________________________ Avg. annual income $____________

11. Applicant to list three personal references:

Name____________________________ Address______________________________

Name____________________________ Address______________________________

Name____________________________ Address______________________________

EDUCATIONAL INFORMATION

12. Describe area of health care in which you are specializing________________________

______________________________________________________________________

13. Are you officially admitted into your health care program? (Yes)______

(No)_______ Where_____________________________________________________

14. Briefly describe your program____________________________________________

______________________________________________________________________

15. Expected year of degree or certificate___________Month/Year___________

16. Colleges/universities attended (list most recent first)

Name and location_______________________________________________________

Dates____________________Grade Avg._________Degree (if any)_______________

Name and location______________________________________________________

Dates____________________Grade Avg._________Degree (if any)_______________

Name and location______________________________________________________

Dates____________________Grade Avg._________Degree (if any)_______________

Describe extracurricular activities____________________________________________

______________________________________________________________________

17. High school(s) attended (list most recent first)

Name and location_____________________________________________________

Years attended______________________Grade average_______________________

Name and location_____________________________________________________

Years attended______________________Grade average_______________________

Describe extracurricular activities__________________________________________

___________________________________________________________________

FINANCIAL INFORMATION

18. List financial assistance received during previous school years

Source________________________________________________________________

Gift or loan__________________________(Amount)___________________________

Source________________________________________________________________

Gift or loan__________________________(Amount)___________________________

19. List positions held, dates employed and amounts earned during the past
school year, including college work/study assignments

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

20. Occupation of spouse__________________ Employer_________________________

21. List current indebtedness--long-term institutional loans, federally insured student loans, other obligations including installment loans:

Description___________________________________________________________

Date due__________ Amount $_________ Amt. due--current basis $________

Description___________________________________________________________

Date due__________ Amount $_________ Amt. due--current basis $________

Description___________________________________________________________

Date due__________ Amount $_________ Amt. due--current basis $________

STUDENT BUDGET (12 MONTH BASIS)

EXPENSES       Actual           Est.                   RESOURCES                 Actual               Est.

Tuition/fees $_______    $_______           Parents contribution $_______          $_______

Out-of-state  _______      _______            Student summer income _______       _______

Books, Supplies _______ ______            Student's personal
and uniforms     _______ _______           assets (available)           _______           _______        

Room & Board  _______ _______           Spouse's contribution _______           _______

Transportation _______ _______           Veteran's benefits
                                                                       (Voc.,Rehab.,GI Bill)        _______          _______

Personal expense_______ _______       Social Security                 _______             _______

Medical expense _______ _______       Federally insured
                                                                      student loans                     _______            _______

Other expenses _______ _______          Other loans                        _______              _______ 

                           _______ _______          Other scholarships            _______            _______

                           _______ _______          Other resources                 _______             _______

Totals               $_______ $_______                           Totals            $_______           $_______

AMOUNT OF ASSISTANCE REQUESTED $_________________

If you are awarded a Jorgensen Scholarship, are you willing to participate or work in the Republic County Hospital, and if a position is not available; are you willing to pursue your chosen profession in Republic County?

(Yes)_______ (No)_______ If you do not return to pursue your contractual agreement, do you understand the loan must be repaid? ___________________.

____________________________________
(Signature of applicant)

Please attach copies of transcripts from the school that you are presently attending and from colleges, universities, or technical schools that you have previously attended.

Attach a typed letter which summarizes your background, your goals and objectives in health care education, and why you believe that you are qualified to receive a Jorgensen Scholarship.

Request your advisor to send a letter with his/her comments regarding your eligibility, scholastic standing and other information relevant to this application.

Should you need additional information about applying for a Family Health Care Scholarship, you may write to the Chairman of the Jorgensen Scholarship Committee or call (785)527-2255.

PETER H. & NELLIE T. JORGENSEN SCHOLARSHIP
NORTH CENTRAL KANSAS HEALTH CARE FOUNDATION
2420 G STREET
BELLEVILLE, KS 66935

ADDENDUM TO JORGENSEN SCHOLARSHIP APPLICATION AND CONTRACT

         Your scholarship will be subject to the following conditions:

1. Employment or professional service time commences subsequent to attainment of degree earned for which money was provided.

i.e. While working as an aide and going to LPN school, time worked DOES NOT fulfill obligation until LPN degree is earned.

2. In most cases, you  may not receive both Jorgensen and State scholarship money. The committee may on special occasions make exceptions with the approval of the NCK Health Care Foundation Board of Directors. Jorgensen money is contingent upon NOT receiving a state scholarship.

3. If you are awarded a Jorgensen scholarship, you will return to work at Republic County Hospital in your chosen field as a full-time or part-time employee. Part-time employee's hours worked will be prorated to complete the fulfillment of the contract. If a position is not available or you are unable to find work in your chosen field, you are expected to pursue your chosen healthcare profession in Republic County. If you do not return to fulfill your contractual agreement in Republic County, the scholarship must be repaid. If said scholarship is not repaid within 6 months of graduation, any unpaid balance will bear interest at the rate of 12% per annum thereafter. The Foundation may agree to allow you to repay said sum over a period of time not to exceed 36 months not including the 6 months immediately following graduation.

4. Should you leave Republic County prior to the fulfillment of your employment time or service time, the scholarship amount due would be prorated based upon your time of service, with interest beginning to accrue upon the date of the ending of your employment or service.

5. Loan forgiveness shall be in writing from the Chairman of the Jorgensen Scholarship Committee.

6. Funds advanced for programs of study not undertaken or completed will be repaid to the Jorgensen Scholarship.

 

Jorgensen Scholarship Applicant

_______________________________

Signature

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