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SCHOLARSHIP APPLICATION FORM

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235 Wealthy SE Grand Rapids, MI 49503-5299 616.840.8000 • 800.528.8989

Mary Free Bed Guild Minority Scholarship Application 2016-2017 Scholarship Program

Deadline: Postmarked by April 1, 2016

SCHOLARSHIP PROGRAM CRITERIA The Mary Free Bed Guild has established annual scholarships for minority students pursuing degrees in nursing, physical therapy, occupational therapy, speech language pathology, therapeutic recreation, neuropsychology or orthotics/prosthetics. An individual is eligible to apply for a one-year scholarship for education-related expenses if he or she meets the established criteria. The scholarship amounts will vary depending on individual needs. Eligibility Requirements:  Black or African American, Asian, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, American Indian or Alaskan Native  Citizen of the United States  Demonstrates a commitment to serving diverse populations  Cumulative college GPA of 3.0 or better on a 4.0 scale (overall and in the chosen area of study)

 Currently enrolled in, or accepted into an accredited college or university as a full-time, degree-seeking student in a nursing, therapeutic recreation, orthotics or prosthetics program; or as a graduate level physical therapy, occupational therapy, neuropsychology or speech language pathology student  Must be a permanent resident in one of the following counties: Oceana, Newaygo, Mecosta, Muskegon, Montcalm, Ottawa, Kent, Ionia, Allegan, Barry, Eaton, Van Buren, Kalamazoo, Calhoun  Demonstrates leadership abilities through participation in community service, extracurricular, or other volunteer activities

INSTRUCTIONS FOR COMPLETING SCHOLARSHIP APPLICATION Please complete the application by typing or printing legibly. Only completed and signed applications will be considered. Please submit the following items with this completed application form. 1. Copy of your most recent transcript of grades from current or last school attended. An official transcript from the school is required by the April 1, 2016 application deadline. 2. Three original letters of recommendation from individuals who are not related to you, the applicant. One must be from a faculty advisor. At least one should reflect your interest in a nursing, therapy or neuropsychology career. All must be in original form, and must be signed and addressed to the Scholarship Selection Committee at the address noted below. 3. On a separate sheet of paper, please specify your involvement, and dates of participation, in community service, extracurricular activities, volunteer involvement, and any awards and honors you have received. 4. On a separate sheet of paper, please prepare a personal statement, not to exceed 1,500 words, indicating your interest in and commitment to a nursing, therapy, neuropsychology, orthotics or prosthetics profession, examples of your involvement in your minority community, your career goals, any other information on significant financial difficulties you are experiencing, and why you feel you should be selected to receive the scholarship. 5. Conduct research of Mary Free Bed Rehab Hospital through the website www.maryfreebed.com and/or other methods of your choice and include observation/comments in your personal statement or as an addendum. 6. Provide proof of citizenship. 7. Provide copy of driver’s license or other State-Issued ID (copies of both front and back). 8. Provide a letter of acceptance into your chosen program. 9. Provide a copy of your complete Student Aid Report (SAR). This is obtained after filing your Free Application for Federal Student Aid (FAFSA) and must show the “Application Receipt Date:” “Processed Date:” and “EFC” (estimated family contribution).

Please submit your completed application to: Attn: Human Resources Department • Mary Free Bed Rehabilitation Hospital • 235 Wealthy SE • Grand Rapids, MI 49503-5299 • [email protected] • 616.840.8000 • 800.528.8989 ext.58667

Mary Free Bed Guild Minority Scholarship Application 2016-2017 Scholarship Program Deadline: Postmarked by April 1, 2016 APPLICANT’S PERSONAL INFORMATION Last Name: ___________________________ First Name: _______________________ Middle ____ Gender

 Female  Male Date of Birth _______/_________/________

Classification for 2016-2017

 College Freshman  College Senior

 College Sophomore  College Junior  Graduate-level Student

Type of Academic Program (please check one)  Nursing (please specify ADN, BSN, MSN or other registered nurse program) _______________________  Therapy (please specify OT, PT SLP, or Therapeutic Recreation) _______________________  Orthotics and/or Prosthetics (please specify) _______________________  Neuropsychology Ethnicity  Native Hawaiian or Other Pacific Islander  Black or African American  Hispanic or Latino  American Indian or Alaskan Native  Asian  Two or more races (all persons who identify with more than one of the above six races) Permanent/Home Address

Temporary/School Address (if different)

Street_________________________________________

Street_________________________________________

City___________________________________________

City___________________________________________

State _________________Zip__________

State _________________Zip__________

Email address______________________________________________________ Day Telephone (_____)___________________________ Evening Telephone (_____)________________________ FINANCIAL INFORMATION Are you receiving other financial aid or support for the upcoming academic year?

 Yes  No

Have you applied for the Mary Free Bed Scholarship in previous years?

 Yes  No

Have you applied for other Scholarships?

 Yes  No

Have you applied for Financial Aid?  Yes  No

If no, why not? ___________________________________________________________________________________ A. INDEPENDENT STUDENT -ORDid you personally file income taxes for the previous tax year?  Yes  No

B. DEPENDENT STUDENT Did your parent or guardian file income taxes for the previous tax year?  Yes  No

If yes, number of dependents you claimed? 

Did your parent or guardian claim you as a dependent?  Yes  No Total number of dependents that your parent or guardian claimed? 

Are you currently employed?

 Yes

 No

Full or Part time? ___________________

Please submit your completed application to: Attn: Human Resources Department • Mary Free Bed Rehabilitation Hospital • 235 Wealthy SE • Grand Rapids, MI 49503-5299 • [email protected] • 616.840.8000 • 800.528.8989 ext.58667

Mary Free Bed Guild Minority Scholarship Application 2016-2017 Scholarship Program Deadline: Postmarked by April 1, 2016 If Employed, where: _______________________________________________________________________ PROJECTED ANNUAL SCHOOL EXPENSES FOR 2016-17 Tuition $__________ Room/Board or Other Housing Expenses __________________________________ $__________ Other Educational Expenses-specify _____ __________________________________ $__________ Other Expenses-specify _______________ __________________________________ $__________ Total Projected Expenses $___________

PROJECTED SOURCES OF INCOME FOR 2016-17 Parents’ Contribution $__________ Grants – specify _______________ _____________________________ $__________ Scholarships – specify ___________ _____________________________ $__________ Student Employment Income _____________________________ $__________ Total Projected Contribution $___________

How did you hear about the Mary Free Bed Scholarship Program?  Friend  School Fair  Faculty  Website  Parent  Other: please specify_____________________________________________________ ACADEMIC INFORMATION Are you currently enrolled or accepted into a nursing, physical therapy, occupational therapy, speech language pathology, therapeutic recreation, neuropsychology or orthotics/prosthetics program at an accredited college or university in the upcoming academic year?  Yes  No Expected Graduation Date from Program ______/_________/_____ List all high schools, colleges and universities attended, including current: Name of School Location Dates Attended

Degree Received

___________________________________________________________________________________________ ___________________________________________________________________________________________ School to which you would apply a MFB scholarship ____________________________________________ AGREEMENT & TERMS OF MARY FREE BED SCHOLARSHIP APPLICANTS I understand that the Mary Free Bed Scholarship Committee may request additional information, including a personal interview, to make a decision on my application. I agree that if this application is accepted and I receive a scholarship award, I will be bound by the terms and conditions of the award. If I am selected for this scholarship, I agree to provide a copy of my official transcript (grades) at the end of each semester. I understand that scholarship funds may only be applied to offset financial obligations that I have incurred or reasonably expect to incur for tuition, room and board, and other educational expenses during the academic year. I further understand that if I receive a scholarship and accept the award, a check for my tuition, room and board (if applicable) will be paid directly to the college or university. I understand that I must submit documentation of other educational expenses, which, upon approval, will be reimbursed directly to me. I further understand that I am responsible for any tax liability incurred because of this award. I certify that the statements that I have provided on this application are true and correct and are given for obtaining a Mary Free Bed scholarship. I authorize Mary Free Bed to verify the statements contained herein and I understand that all personal information contained on this application will be held in confidence by the Scholarship Selection Committee.

Applicant's Signature __________________________________________ Date _____________ For questions or additional information please contact Human Resources at [email protected]

Please submit your completed application to: Attn: Human Resources Department • Mary Free Bed Rehabilitation Hospital • 235 Wealthy SE • Grand Rapids, MI 49503-5299 • [email protected] • 616.840.8000 • 800.528.8989 ext.58667

Mary Free Bed Guild Minority Scholarship Application 2016-2017 Scholarship Program Deadline: Postmarked by April 1, 2016

• 616.840.8000 • 800.528.8989 ext.58667

Please submit your completed application to: Attn: Human Resources Department • Mary Free Bed Rehabilitation Hospital • 235 Wealthy SE • Grand Rapids, MI 49503-5299 • [email protected] • 616.840.8000 • 800.528.8989 ext.58667

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SCHOLARSHIP APPLICATION FORM

235 Wealthy SE Grand Rapids, MI 49503-5299 616.840.8000 • 800.528.8989 Mary Free Bed Guild Minority Scholarship Application 2016-2017 Scholarship Pro...

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