|Memorial Hospital of Carbondale Auxiliary
Phone: (Home) ____________________________ (Cell) ________________________
Marital Status: __________________________________________________________
Dependents: (if applicable) ________________________________________________
(Age and Relationship)
What is your professional goal? _____________________________________________
What is your course of study? _______________________________________________
What school are you currently attending? _____________________________________
What school do you plan to attend? __________________________________________
Have you been accepted? __________________________________________________
Will you attend full time or part time? _____________ (scholarship is awarded only to full time students)
Expected graduation date? _________________________________________________
Please list all schools attended, with information requested below, (including high school):
School Name City/State Degree Year GPA
Please list all honors received and when:
List volunteer work performed; i.e. civic or religious organizations:
Current Employer and Position ______________________________________________
What is your current annual income? _________________________________________
If applicable, your parents &/or spouse’s income? _______________________________
What other financial obligations do you have? __________________________________
How will this scholarship be used? ___________________________________________
Hare you/or are you a recipient of any other scholarships, partial or full? If yes, what other scholarships & their monetary value have you received? _____________________ Are you employed by or related to someone employed by Southern Illinois Healthcare?
If the answer is yes, who? (example: yourself, spouse, parent) ____________________
If so, which facility and department? _________________________________________
Please make any comments below, attach additional sheets as needed:
The following information needs to be submitted along with the completed application:
Two recommendation letters from teachers, administrators or managers.
If a SIH employee, one recommendation letter must be from your current SIH supervisor.
Official transcripts from all educational facilities attended.
A copy of the acceptance letter into your chosen school/program.
A one page essay on your reasons for choosing this career field and why you believe you should receive t his MHC Auxiliary sponsored scholarship.
The requested documents are to be returned in a sealed envelope and send to the address listed below.
Volunteer Services/Auxiliary Scholarship Program
Memorial Hospital of Carbondale
405 West Jackson Street
Carbondale, Illinois 62901
Consent for Release of Information
I hereby authorize the release of any information requested by MHC Auxiliary that may be of assistance in evaluating my scholarship application. I also attest that the information provided in this application is complete and accurate.
Signature of Applicant: ___________________________________________________
Applications are due by May 31st into the office of
Volunteer Services at Memorial Hospital of Carbondale.
Only persons receiving the MHC Auxiliary Scholarship will be notified.
Important additional information: This scholarship is available only full time students who have been accepted into a medically related healthcare field. Completing pre-req’s to be accepted into a field of study do not qualify. This scholarship is paid only to the school of acceptance and is to be used only for tuition and/or books. This scholarship cannot be used for travel, living expenses, etc.
This scholarship is renewable annually for qualified applicants, but limited to no more than four years. Final decisions/selections of scholarship recipients is made by the MHC Auxiliary Scholarship Committee. Receiving the scholarship once does not guarantee renewal the next year, applicants must meet scholarship guidelines.
The Scholarship Committee reserves the right to make judgments in cases not covered by guidelines.
File Name: 2014 MHC Auxiliary Scholarship Application