Scholarship Application - North Country Hospital

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Date of Birth *

Education Background

High School Attended

Graduation Year

If you are currently enrolled in or have previously attended a post-high school program, please list the institution(s) and dates of attendance.

Intended Healthcare Career Field

College or Training Program Plans

Estimated Total Cost per Year (First Choice)

Second Choice (optional)

Estimated Total Cost per Year (Second Choice)

Third Choice (optional)

Estimated Total Cost per Year (Third Choice)

Personal Statement

Please describe your career goals and how this scholarship will help you achieve them.

Financial Information

If yes, please list amounts received or expected.

Please describe any unusual financial circumstances (medical expenses, trust funds, etc.).

Household Financial Information - (Parents’ information if applicable)

Combined Gross Household Income

Market Value of Primary Home

Address dates you

Unpaid Mortgage Balance (Farm or Business)

Unpaid Mortgage Balance (Farm or Business) (copy)

Other Assets (vacation property, etc.)

Student Savings and Assets

Expected Student Summer Earnings

Estimated Family Contribution Toward Education This Year

Other Sources of Financial Support (parents, grandparents, etc.)

Activities and Experience

Please describe your out-of-school activities and work experience.

Please describe any school activities and leadership roles (if applicable).

Upload your most recent academic transcript

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Certification

I certify that the information provided is accurate and complete to the best of my knowledge. *

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Signature *

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Date