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NURSING EDUCATION ASSISTANCE PROGRAM 2018 Nursing Scholarship Application

Dear Nursing Scholarship Applicant,

The Baylor Scott & White Health (BSWH) Nursing Scholarship Program provides

support for the education of nurses in Central Texas. Applications are accepted between

April 16 and July 16, 2018. Please provide all requested items in the checklist.

Checklist

Application for Nursing Scholarship Program

Most recent academic transcript, highlight GPA reflected on application

(unofficial is acceptable)

Professional reference as required (instructions found on pg 5&6)

Recommendation from Supervisor (BSWH employee only)

Applications will NOT be considered if they are:

Turned in after July 16, 2018 @ MIDNIGHT

Missing any item from the checklist

Please Note:

Use only the space provided

Do not add extra pages or letters

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I. Personal Information:

A. Legal Name:

Personal E-mail Address:

Mailing Address:

City: State: Zip:

Cell Phone Number: ( )

B. Are you a United States Citizen? YES NO

C. Are you a natural born US Citizen? YES NO

D. Are you authorized to work in the United States? YES NO

E. Have you served in the US armed forces? YES NO

F. Prior education:

Graduation Date Program Emphasis School

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II. Education and Experience:

A. Overall GPA reflected on most current transcript:

B. Nursing school you are planning on attending:

C. Nursing Program you wish to complete:

LVN to ADN ADN ADN to BSN ADN to MSN

BSN MSN Doctorate

D. Nursing program enrollment date: (month & year)

a. *Enrollment may not be pending at the time of application

E. Nursing program anticipated graduation date: (month & year)

F. Are you a member of a professional nursing or allied health organization?

a. YES NO

b. If yes, please list the name of the organizations:

G. Do you hold a current State of Texas Nursing License?

a. YES NO (If yes, please answer the following questions)

b. Type of License: RN LVN

c. Nursing License Number:

H. Are you employed at Baylor Scott & White Health?

a. YES NO (If yes, please answer the following questions)

b. Date of Hire: Years of Service:

c. Current Position: Department / Unit:

d. BSWH Email:_____________@BSWHealth.org Extension: ___________

e. Supervisor/Manager Name:

FULL TIME PART TIME PRN

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III. In the space provided, please share some of your educational and career goals:

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To be completed for BSWH and non-BSWH Employees

IV. Professional Reference One - (Previous Colleague or Academic Faculty)

Name of Candidate:

Please rate applicant on items 1 through 4 and provide comments as needed:

Scale: 1 – Lowest 5 - Highest

1. Applicant has a strong work ethic:

1 2 3 4 5

2. Applicant demonstrates excellent leadership skills:

1 2 3 4 5

3. Applicant has an exceptional ability to relate to others:

1 2 3 4 5

4. Applicant has the ability to positively impact the profession of nursing:

1 2 3 4 5

5. How long have you known the candidate and in what capacity?

6. Please make any additional comments concerning the candidate that you feel would

qualify him/her for consideration:

Your name:

Place of Employment:

Title:

Preferred Email:

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To be completed for non-BSWH Employees ONLY!

V. Professional Reference Two - (Previous Colleague or Academic Faculty)

Name of Candidate:

Please rate applicant on items 1 through 4 and provide comments as needed:

Scale: 1 – Lowest 5 - Highest

7. Applicant has a strong work ethic:

1 2 3 4 5

8. Applicant demonstrates excellent leadership skills:

1 2 3 4 5

9. Applicant has an exceptional ability to relate to others:

1 2 3 4 5

10. Applicant has the ability to positively impact the profession of nursing:

1 2 3 4 5

11. How long have you known the candidate and in what capacity?

12. Please make any additional comments concerning the candidate that you feel would

qualify him/her for consideration:

Your name:

Place of Employment:

Title:

Preferred Email:

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VI. BSWH EMPLOYEES ONLY: RECOMMENDATION FROM SUPERVISOR

I recommend (Name of applicant) for the BSWH

Nursing Scholarship. The applicant has exhibited an overall satisfactory performance

rating.

Comments:

Questions to be completed by supervisor…

Scale: 1 – Lowest 5 - Highest

1. Attendance: 1 2 3 4 5

2. Problem Solving: 1 2 3 4 5

3. Team Player: 1 2 3 4 5

4. Would you hire into future

nursing position? Yes No

Supervisor Name:

Supervisor Signature:

Supervisor Unit and Title:

Extension: Date:

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VII. TERMS OF NURSING EDUCATION ASSISTANCE PROGRAM

If, I receive a nursing scholarship, I agree and understand the following conditions:

1. To provide copies of grades within two weeks of the end of each semester. Grades

must be scanned (as a PDF) and emailed, to Naomi Thompson at

Naomi.Thompson@BSWHealth.org

2. Any change in enrollment status must be reported, in writing, within 48 hours of the

change.

3. Attendance of the Annual Scholarship Luncheon, held in November, is mandatory

4. Unless otherwise allowed by the assistance program I am awarded,1 I agree to use the

scholarship money solely for the payment of Qualified Expenses. “Qualified

Expenses” shall mean tuition and fees required for enrollment or attendance in the

Program and other fees, books, supplies and equipment required for instruction in the

Program, but shall not mean general living expenses, such as room, board, travel or

incidental living expenses.

5. I understand that I am solely liable for complying with any requirements for the

reporting of the scholarship money as income and the payment of any applicable taxes,

whether federal, state or local, that may be levied by any governmental authority on the

scholarship money under this Agreement.

6. I agree that copies of my application and grades may be reported to the donor of the

assistance program I am awarded.

Signature of applicant:

Date signed:

Application and all documentation must be scanned and emailed to

Naomi Thompson at Naomi.Thompson@BSWHealth.org

PLEASE DO NOT DELIVER IN PERSON OR MAIL

1 Lowther Scholarship permits a monthly allowance for living expenses.