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

PERSONAL INFORMATION                                                                     January Feburary March April May June July August September October November December Month  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date  2008 2009 2010 2011 2012 Year

1. Legal name

Last      First  Middle  Maiden
                       

2. Social Security No. - -

3. Permanent home  address                                                       4. Campus Address:

   Street                   Street

City                 City

State            zip code                            State            zip code

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) 1 2 3 4 5 6
 

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 guardian 
 

address         City       State  zip code
 

Occupation(s)Avg. annual income $

11. Applicant to list three personal references:

NameAddress

NameAddress

NameAddress


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 1 2 3 4 5 6 7 8 9 10 11 12 Month      Year 2007 2008 2009 2010

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

Name and location

DatesGrade Avg.Degree (if any)

Name and location

DatesGrade Avg.Degree (if any)

Name and location

DatesGrade 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       loan (Amount)

Source    

      Gift         loan(Amount)

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

20. Occupation of spouseEmployer

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?

By checking this box you are agreeing with the terms  listed above in this application
 

The following information below can be submitted in the following ways by mailing to Karrie Holmes 2420 G St. Belleville KS 66935 or attaching  and sending to the following e-mail address click here to attach and e-mail information to  Karrie Holmes.

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  send to Karrie Holmes 2420 G St. Belleville KS 66935 or attach and send to the following e-mail address

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

By checking here you are adding your signature to this application and submitting that all you information is accurate and true to the best

of your ability and that you agree with the terms above stated in this application.