Associate Degree Nursing Scholarship

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Associate Degree Nursing Scholarship Application Spring Postmark Deadline: March 24, 2009 Fall Postmark Deadline: September 11, 2009 Giving Golden Opportunities by: Increasing the supply of registered nurses practicing in medically underserved areas Improving access to healthcare in rural and urban areas of California Helping students pursue a career in the health professions Awarding nurses who are dedicated to practicing in underserved communities Application Instructions You must be a California resident and a citizen or permanent resident of the U.S. to apply. The purpose of the Associate Degree Nursing (ADN) Scholarship is to increase the number of registered nurses (RN) practicing in medically underserved areas (MUA) of California.

Applications for the Associate Degree Nursing Scholarship are accepted bi-annually. Monies awarded under these programs are intended to pay tuition, required fees, books, supplies, and educational equipment costs related to the applicant 9s registered nurse education. All awards are subject to the availability of funding.

Recipients will be required to sign a written contract with the Foundation outlining the provisions which must be met to fulBll the obligations under this program. Failure to comply with the terms of the contract may result in the awardee 9s repayment of the funds awarded plus interest. Applicants who ... more. less.

owe a service obligation to practice direct patient care to another entity entered into before Bling an application with the Foundation are ineligible to receive a scholarship. Previous obligations must be completed before applying. Awardees who breach their contract with the OSHPD/HPEF will not be allowed to reapply for additional awards. SELECTION CRITERIA Selection for the ADN Program is based solely on information contained in the application and supporting documentation. Selection for awards is based on the following criteria: Counties in most need of Registered Nurses Work Experience - nursing and non-nursing work experience in a MUA. Financial Need - actual or potential difBculty in completing education in the absence of an award. Career Goals - professional goals for the next Bve (5) to ten (10) years. Cultural / Linguistic Skills & Abilities - Culture and language experiences; for example, employment, school, travel abroad, and family settings. Community Service - documented volunteer service and/or activities, particularly in a MUA. Community Background - Family structure, socio-economic background and community where the applicant grew up. Academic Performance - prior and current academic performance; potential for future academic success. Priority will be given to applicants whose community background and commitment indicates the likelihood of long-term employment in a MUA even after the service obligation has ended. Awards are made on a competitive basis. Each part of the application must be completed. All supporting documentation must be submitted by the appropriate deadline. Only complete applications will be evaluated. The Foundation will not notify individuals if their application is incomplete. Scholarship Eligibility Students may receive up to $10,000 for the Associate Degree Nursing Scholarship . Scholarships are funded for one (1) academic year, generally two (2) semesters or three (3) quarters. Your graduation date may impact the amount of funding you are eligible to receive. Scholarship Eligibility - Scholarships are available to students who are enrolled or accepted in an Associate Degree Nursing Program. Priority will be given to students who will be graduating within one (1) to two (2) years. Awardees must sign a contract with the OfBce of Statewide Health Planning and Development (OSHPD)/Health Professions Education Foundation and agree to the following terms: Complete a two (2) year service obligation to practice in a MUA of California as a RN providing full-time (40 hours per week or its equivalent) direct patient care. Be a full-time or part-time student (no less than six (6) units) in a California accredited school. Maintain a minimum cumulative GPA of 2.0 each year scholarship funds are sought. SUBMIT THE FOLLOWING 1. Completed Application Complete all pages of this application. It must be completed, signed, and dated to be considered eligible. 2. OfAcial Tran:cript(:) Related To Yo<r N<r:ing Ed<cation If you are a student in your Brst year of the nursing program and your transcripts do not reCect your nursing education, submit your most current transcript. The transcript(s) must be marked ofBcial by the school and delivered to the Foundation in a sealed envelope. The Foundation will not accept unofBcial transcripts, copies or print outs of transcripts, or transcripts in an open/unsealed envelope. If yo< want receipt conAr5ation of yo<r application packet, plea:e :<+5it one :elf-addre::ed :ta5ped envelope with yo<r applica tion. ADN Application Instructions (cont.) 3. Personal Statement (Part D of the Application) Attach your personal statement to the application. Your statement must be typed and no more than two (2) pages. Statement must provide a comprehensive response to each question. Restate and number each question along with your answer. Personal statements that lack detail may be considered incomplete and therefore, ineligible. 4. Two Profe::ional Letter: of Reco55endation Letters of recommendation must be dated within six (6) months of the application deadline. The letters must be on letterhead or include the author 9s title, name of employer, mailing address, and phone number. It is recommended that at least one (1) letter be from a faculty member. To receive maximum credit for community service, a letter from the agency where service was provided must be submitted. 5. Grad<ation Date VeriAcation For5 This form must be signed by the nursing program director or a faculty member authorized to sign on the director 9s behalf. The Graduation Date VeriBcation Form is enclosed as part of the scholarship application. Applicants can also download this form from the Foundation 9s website at www.healthprofessions.ca.gov. 6. Linguistic Competency Fluency in a second language must be veriBed on the Employment or Graduation VeriBcation form from an employer or school faculty. 7. Student Aid Report (SAR) Students must submit the Bnal 2009-2010 SAR. The SAR must indicate the student 9s expected family contribution (EFC). The FAFSA is available from all college Bnancial aid ofBces and is also available on the Internet at www.ed.gov/ofBces/OPE/express.html. DO NOT submIT FAFsA. OR signed 2008 Federal Tax Ret<rn and all W-2: - Applicants who do not apply for Bnancial aid must submit a complete copy of their 2008 Federal Tax Return and all W-2s. DO NOT sEND YOuR sTATE TAX RETuRN. APPLICATION SUBMISSION Applications must be postmarked by the deadline. In order to be eligible, each part of the application must be completed. All supporting documentation must be submitted by the appropriate deadline. The Foundation will not notify applicants if their application is received incomplete. Applicants are urged to contact the Foundation at (800) 773-1669 prior to the Bnal Bling date to verify if their application was received complete. Do not bind or submit applications in a loose-leaf binder. NOTIFICATION OF AWARDS The Foundation will notify applicants of their application results within 120 days of the postmark deadline. For additional information on how to complete this application, please visit the Foundation 9s website to access Frequently Asked Questions, a technical assistance call and a powerpoint presentation. sPRING POsTmARK DEADLINE: mARCH 24, 2009 FALL POsTmARK DEADLINE: sEPTEmbER 11, 2009 s<+5it application: to: Health Profe::ion: Ed<cation Fo<ndation ADN Scholarship Program 400 R Street, Suite 460 sacra5ento, CA 95811 (800) 773-1669 or (916) 326-3643 ADN " Mr. " Mrs. " Ms. " Dr. Last Name: First Name: Middle Initial: CA Drivers License Number: *Social Security N umber: Mailing Address: City: State: Zip Code: County: Permanent Address (if different than above) : City: State: Zip Code: County: Home Phone: ( ) Date of Birth: Cell Phone: ( ) E-mail Address: Work Phone: ( ) Gender: " Male " Female Marital Status (Optional): " Unmarried " Married Are you a citizen or permanent resident of the U.S.? " Yes " No Are you a California resident? " Yes " No Number of dependents other than self and spouse (as declared on tax returns or student aid report): Which best describes your ethnic background: " African American " Caucasian " Native American " Asian American " Hispanic/Latino " PaciBc Islander " Other (Please specify) ___________________________ PART A - PERSONAL INFORMATION Appllicants may apply for only one award using this application (Please type or print your answers legibly in the space provide d). FOR OFFICIAL USE ONLY Recd: Reviewed by: Inp<t by: O5itted: App Pgs GDV EVF SAR TAX LoR Other Co55ent:: CT#: Co5pl / Inc: muA: Ye: / No Application Please refer to the application instructions when completing the application. Complete all pages of the application form, and m ake sure all supporting documents are submitted with your application. All documents must be postmarked by the application deadline. Late or incomplete application p ackets will not be evaluated. *MANDATORY DISCLOSURE OF U.S. SOCIAL SECURITY NUMBERS Disclosure of your U.S. Social Security Number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 (42USCA 405(c)(2)(C)) authorize collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code, or for veriBcation of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number your application will not be processed AND you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you. PERSONAL INFORMATION NOTIFICATION The Information Practices Act of 1977 and the Federal Privacy Act require this program to provide the following to individuals who are asked by the OfBce of Statewide Health Planning and Development, Health Professions Education Foundation to supply information: The principal purposes for requesting personal information are for veriBcation of identiBcation, establishment of eligibility and program administration. Program regulations (Chapter 14 of Title 22 of the California Code of Regulations, Sections 97701 et seq.) require every individual to furnish appropriate information for application to the Associate Degree Nursing Scholarship Program. All requested information is required unless it is speciBcally identiBed as voluntary. Failure to furnish this information may result in the return of the application as incomplete. An individual has a right of access to records containing his/her personal information that are maintained by the OfBce of Statewide Health Plan - ning and Development, Health Professions Education Foundation. The person responsible for maintaining the information is the Program Director, Health Professions Education Foundation, 400 R Street, Suite 460, Sacramento, CA 95811, (916) 326-3640. The Foundation may charge a small fee to cover the cost of duplicating this information. ADN Page 1 Please enter the award amount you are requesting (up to $10,000): _______________________ Application (cont.) Applicant 9s Name: ___________________________________ PART B 3 COMMUNITY BACKGROUND Have you lived in an economically disadvantaged background (income below the federal poverty level, low income, subsidized income,qualiBed for public program, lived in rural, inner city or medically underserved area) for at least two years? " Yes " No If you selected yes; please describe in your personal statement under question #5. If yes, please check the appropriate range of years. " 2-5 years " 6-10 years " 11 or more years PART C 3 LINGUISTIC COMPETENCY 1 . List any languages in which you are fluent. This must also be veriBed by the applicant 9s employer on the Employment VeriBcation or CertiBcation of Enrollment Form. 1st language: _______________________________________ 2nd language: ____________________________________________ 3rd language: _______________________________________ PART D 3 PERSONAL STATEMENT Attach your personal statement to the application. Your statement must be typed and no more than two (2) pages. Restate and number each question along with your answer. Personal statements that lack detail may be considered incomplete and therefore, ineligible. 1. What kind of work would you like to do immediately after graduation? 2. What kind of work do you think you 9ll be doing in Bve (5) years? 3. What are your professional goals for the next Bve (5) to ten (10) years, as they relate to a health profession? 4. Describe any community service, volunteer activities, or club memberships within the past two (2) years (Please attach any letters of recommendation you may have. Do not include experience for which you received academic credit.) 5. Describe your family background including your parent or guardian 9s occupation, marital status, family size such as number of dependents including yourself, where you were raised, Brst in family to attend college, English as a second language and any other factors that help describe your family 9s socio-economic situation. 6. Describe how your background is relevant to your interest in pursuing a nursing career. Do you see your background as an advantage, disadvantage, or both? 7. Describe your experiences in cross-cultural situations which may include employment, school, travel abroad, and family settings. PART E 3 QUESTIONNAIRE Do you currently owe a service obligation to another entity? " Yes " No cService Obligation d means the contractual obligation agreed to by the recipient of the scholarship or loan repayment where the recipient agrees to practice their profession for a specified period of time in or through a designated facility. Are you a previous awardee of the Foundation? " Yes " No If yes, please enter the contract # _______________________ Are you currently a military veterans? " Yes " No Are you the Brst in your family to attend college? (optional) " Yes " No Where did you hear about the Associate Degree Nursing/Pre-Nursing Program? (Check all that apply) " Work (employer or co-worker) " Friend/Acquaintance " TV " Radio " Foundation website " Other website " Advertisement " Newspaper or publication (please specify) ______________________ " Organization or AfBliation (please specify) _______________________ " Other source (please specify) _________________________________ Where did you receive the Associate Degree Nursing Program application? (Check only one) " Program Director/Instructor " Foundation OfBce " Foundation website " Other website " Work (employer/co-worker) " Friend/Acquaintance " Other (please specify) _____________________________________ PART F - ADN APPLICANT ( only LVN to ADN applicants ) If you are a licensed Vocational Nurse and you are not awarded by the ADN program, your application may be automatically considered eligible for the LVN to ADN program. " Yes, please submit this application to the LVN to ADN program " No, please do not submit this application to the LVN to ADN Program. PART G - APPLICATION CERTIFICATION I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the Health Professions Education Foundation (Foundation) to verify any information submitted as part of this application. I understand that falsiBcation of information contained in this application will disqualify my application and that the Board of Registered Nursing will be notiBed. I understand that if falsiBcation is discovered after I have been awarded or if I breach my contract, I will be required to repay all funds awarded, plus interest and administrative fees. I understand that once submitted, my application and supporting documents become the property of the Foundation. I also understand that my personal statement becomes the property of the Foundation and may be used, including but not limited to, advertising/marketing, program reports, newsletters, and other publications. Last Name: ___________________________________________________ First Name: ________________________________ Middle Initial: ________ Applicant 9s Signature: ___________________________________________ Date: _______________________________________________________ ADN SCHOLARSHIP CHECKLIST " 1. Completed Application (signed) " 2. OfBcial Transcript(s) related to your nursing education " 3. Personal Statement " 4. Two (2) Professional Letters of Recommendation (dated within 6 months) " 5. Graduation Date VeriBcation Form " 6. Copy of the cost of attendance/tuition for RN program " 7. 2009/2010 Student Aid Report or Signed 2008 Federal Tax Return and all W-2s ADN Page 2 Work History Please list all work experience. List most recent employer frst (maximum of four (4) employers). Employer 9s Name: _____________________________________________ Street Address: _______________________________________________ City: ______________________ State: ________ Zip Code: ____________ County: ______________________________________________________ Supervisor 9s Name: ____________________________________________ Telephone Number: ____________________________________________ Your Position/Title: ____________________ Monthly Salary: ____________ " Full-time OR " Part-time Employment Start Date: _____/_____/_____ Employment End Date: _____/_____/_____ Average hours worked (please choose only one): _______/day _______/week _______/month Brief Description of your job duties: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________________________________ ____________________________________________________________ Employer 9s Name: _____________________________________________ Street Address: _______________________________________________ City: ______________________ State: ________ Zip Code: ____________ County: ______________________________________________________ Supervisor 9s Name: ____________________________________________ Telephone Number: ____________________________________________ Your Position/Title: ____________________ Monthly Salary: ____________ " Full-time OR " Part-time Employment Start Date: _____/_____/_____ Employment End Date: _____/_____/_____ Average hours worked (please choose only one): _______/day _______/week _______/month Brief Description of your job duties: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________________________________ ____________________________________________________________ Employer 9s Name: _____________________________________________ Street Address: _______________________________________________ City: ______________________ State: ________ Zip Code: ____________ County: ______________________________________________________ Supervisor 9s Name: ____________________________________________ Telephone Number: ____________________________________________ Your Position/Title: ____________________ Monthly Salary: ____________ " Full-time OR " Part-time Employment Start Date: _____/_____/_____ Employment End Date: _____/_____/_____ Average hours worked (please choose only one): _______/day _______/week _______/month Brief Description of your job duties: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________________________________ ____________________________________________________________ Employer 9s Name: _____________________________________________ Street Address: _______________________________________________ City: ______________________ State: ________ Zip Code: ____________ County: ______________________________________________________ Supervisor 9s Name: ____________________________________________ Telephone Number: ____________________________________________ Your Position/Title: ____________________ Monthly Salary: ____________ " Full-time OR " Part-time Employment Start Date: _____/_____/_____ Employment End Date: _____/_____/_____ Average hours worked (please choose only one): _______/day _______/week _______/month Brief Description of your job duties: ______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________________________________ ____________________________________________________________ ADN Page 3 Applicant 9s Name: ___________________________________ Student 9s Last Name: _______________________ First Name: _____________________ Middle Initial: _________________ School Name: _____________________________________________________________________________________________ Program Enrolled: __________________________________________________________________________________________ School Mailing Address: ______________________________________________________________________________________ City: ______________________________ County: ______________________ State: _______ Zip Code: ______________ Year Entered (Month / Year): _______________________ Expected Graduation Date (Month / Year): ______________________ Enrollment Status: " F/T or " P/T # of units currently enrolled: _________ C<rrent GPA: ________________ or # of units equivalent if on a modular system: __________ Please comment on the student 9s performance and potential for academic success. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Please attach a copy of any record showing the tuition costs for the program the student is enrolled or accepted in Through our selection process, I have determined that the applicant can speak the following language(s): 1st language: _________________________________________________ 2nd language: ________________________________________________ 3rd language: _________________________________________________ Name: ( Please Print ) ________________________________ Signature: ________________________________________ Title: _____________________________________________ Phone Number: ____________________________________ Fax Number: ______________________________________ Email: ___________________________________________ ATTENTION! The completed form must bear an original ink signature. Photocopies and faxed copies of the completed form are not acceptable. FORM TO BE COMPLETED BY THE PROGRAM DIRECTOR OR AN APPROPRIATE DESIGNEE ( The person signing this form may not be related to the applicant by blood, marriage, or adoption ) Graduation Date Verification Form Attach Business Card Here (For ADN Scholarship Applicants Only) ADN Page 4 BOARD OF TRUSTEES Gary Gitnick, M.D., Chairman Chie f, Division o f Digestive Diseases and Pro fessor o f Medicine, UCLA Los Angeles, CA Diana Bontá, R.N., Dr.P.H. Vice President, Public A\x2airs, Kaiser Permanente Pasadena, CA Brenda Jackson Drake, J.D. Director, Public Health 6rust Irvine, CA Richard Fantozzi, M.D. President, Te Medical Board o f Cali fornia San Diego, CA Tadao Fujiwara, M.D., Pharm. D. Los Angeles, CA Barb Johnston, M.S.N. Executive Director, Medical Board o f Cali fornia Sacramento, CA Marcella Low Public A\x2airs Manager, Te Gas Company Redondo Beach, CA Linda Lucks Venice, CA Anmol Singh Mahal, M.D. President, Te Cali fornia Medical Association Fremont, CA Joseph Ruben Martel, M.D. Rancho Cordova, CA Deepak K. Rajpoot, M.D. Chie f o f Pediatric Nephrology, UCIMC Orange, CA Barbara Yaroslavsky Member, Medical Board o f Cal fornia Los Angeles, CA EX 3OFFICIO MEMBERS David M. Carlisle, M.D., Ph.D. OSHPD Director Sacramento, CA Jimmy H. Hara Chair, Healthcare Work force Policy Commission Los Angeles, CA FOUNDATION STAFF Lupe Alonzo-Diaz, M.P.Af. Executive Director Sharon Cardoso Director o f Program Administration James E. Hall Program Ofcer Revised 12-23-2008 400 R Street, Suite 460 Sacramento, CA 95811 www.healthprofessions.ca.gov (800) 773-1669

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