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CROSSING RIVERS HEALTH SCHOLARSHIP

APPLICATION FORM
APPLICANT:

This form must be completed for consideration to receive a Crossing Rivers Health
Scholarship for education in a health occupation, with the exception of those
pursuing medical school. Please complete the application with the help of your high
school and submit it to the office of the Chief Executive Officer at Crossing Rivers
Health no later than Wednesday, March 16, 2016.

ATTACHMENTS:

1.

Essay stating your intent to pursue a health occupation and why


(must be approximately one page in length).

2.

Letter of Recommendation

NAME

PARENT/GUARDIAN

TELEPHONE

ADDRESS

CITY
SSN

STATE

ZIP

HIGH SCHOOL

HIGH SCHOOL ADDRESS


CITY

STATE

ZIP

STATE

ZIP

HEALTH OCCUPATION COURSE OF STUDY


COLLEGE WILL BE ATTENDING
TELEPHONE
CITY

ADDRESS

**THE INFORMATION HEREIN IS TRUE TO THE BEST OF MY KNOWLEDGE**


*Any Willfull Misrepresentations May Disqualify the Applicant*
STUDENT'S SIGNATURE

DATE

PARENT OR
GUARDIAN'S SIGNATURE

DATE

PRINCIPAL OR
COUNSELOR'S SIGNATURE

DATE

==========================================================================

OBJECTIVE CRITERIA
I.

College entrance examination score (ACT or SAT)


ACT composite score

and/or

SAT combined score

II. Student's cumulative high school grade point average (GPA) using a 4.0 base.
III.

Please attach High School transcript.

IV.

Total number of family members living at home (including yourself):


Number of dependents in your parent's family (including yourself):
Ages (including yourself)

No. Attending College (including yourself)

Estimated Tuition Expense per Semester


V.

Extracurricular Activities Organizations and Clubs (Show years of involvement; also,


please indicate any offices held):

Honors and Awards

Community and Other Activities

VI.

Work Activities Are you employed?

Yes

If yes, what type of work and how many hours per week?

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03/2016

No

CROSSING RIVERS HEALTH SCHOLARSIP


RULES AND REGULATIONS
TITLE:

Rules and Regulations Governing Scholarship Awards

PURPOSE
AND
OBJECTIVE:

The Scholarship Committee of Crossing Rivers Health hopes to aid educational


endeavors of the service area's youth by offering scholarships to area graduating high
school seniors. These scholarships will be offered in the form of grants to students who
aspire to continue their education in a health care occupation, with the exception of those
intending to apply for medical school. It is the committee's intent that this program will
promote higher education in the health care occupations. It is considered an investment
for continued professional staff recruitment at Crossing Rivers Health and those facilities
operated by Community Health Services Corporation.

Following are the guidelines for governing the scholarship program:


1.

The Scholarship Committee of Crossing Rivers Health will award scholarships each year to
qualifying students who are pursuing higher education in a health care occupation. The number of
scholarships awarded for health occupations will be based upon the finances available in the
scholarship account. The maximum amount of a scholarship is $8,000.

2.

Scholarships for health occupations shall be awarded to graduating high school seniors from the
hospitals health care service area.

3.

The Chief Executive Officer or his designee will contact the area school guidance departments
regarding the availability of the scholarship program.

4.

Selected scholarship applicants, along with their parent(s) and/or guardian(s), will be interviewed by
Crossing Rivers Healths Scholarship Committee or a designee. The Chief Executive Officer or his
designee will also contact the respective school guidance counselor regarding applicants for the
scholarship.

5.

Scholarships will be awarded based upon the following criteria (not necessarily listed in the order of
importance):

6.

a.

Scholastic Ability (class standing, extra curricular activity)

b.

Administrative Interview and Recommendation

c.

Applicants must be accepted into or enrolled in a health occupation program.

d.

Future employment at Crossing Rivers Health or those facilities operated by Community


Health Services Corporation will be given important consideration in awarding the
scholarships.

The Scholarship Committee of Crossing Rivers Health will review and make the final decision on
the awarding of scholarships.

Crossing Rivers Health


Scholarship Rules and Regulations
Page 2
7.

The Crossing Rivers Health Scholarship Committee shall be responsible for investing scholarship
funds in a timely manner; all accounting and reports relating to the scholarship fund shall be
prepared by the Chief Executive Officer or his designee.

8.

Scholarship funds will be paid directly to the college designated by the recipient with the first year
payment being submitted at the beginning of the second semester. Subsequent payments will be
submitted at the beginning of each of the following semesters. Total payments will not exceed
$8,000.

9.

A commitment of employment at Crossing Rivers Health or those facilities operated by Community


Health Services Corporation is a condition of the awarded scholarship. Scholarship funds are
forgiven at the rate of $1.50 per hour for each hour worked as an employee. If there is not a position
available within 60 days of graduation, the loan is forgiven in its entirety.

10.

Recipient must maintain good progress and academic standing in the program. Nonconformance or
withdrawal from the program will require immediate payback of all funds to Crossing Rivers
Health. The balance due shall include the principal plus interest computed at an annual rate and
compounded quarterly from the date of disbursement.

11.

All applications become the property of Crossing Rivers Health.

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