PEKINHOSPITALAUXILIARY

P E K I N H O S P I T A L A U X I L I A R YFINANCIAL ASSISTANCE APPLICATIONINSTRUCTIONS AND POLICIES1.The Pekin Hospital Auxiliary each year gives financial assistance to students enrolled in a health care professions program.2.Students living in the Pekin area are eligible to apply. Priority, of course, is extended to those who intend to return to the Pekin area to practice their professional skills.3.This assistance is awarded on an annual basis, so an application must be submitted each year. Recipients will not be eligible for more than four years of assistance.4.Completed applications, copies of grades, letters of recommendation, verification of income (applicants W-2 must accompany application if self supporting or W-2 for parents if applicant is a declared dependent for their parents), and other pertinent information must be delivered to Pekin Hospitals Volunteer Services Department no later than 4:30 p.m. on Friday, April 14, 2017. We are not responsible for applications delivered to any other department in the hospital. If sending by mail, all pertinent information must be received by Volunteer Services Department post-marked no later than April 14, 2017.Pekin HospitalVolunteer Services600 S. 13th StreetPekin, IL 615545.The committee will review applications and make decisions with consideration to:A.Course of studyB.Scholarship achievementsC.Course requirementsD.InterestE.Letters of recommendationF.General qualificationsG.Financial need6.Recipients and non-recipients of financial assistance awards will be notified byJune 16, 2017.7.For additional applications or should you have questions, please contact the main Pekin Hospital phone number at 309 347 1151 and ask for Volunteer Services.auxil/scholars/ scholarship applicationP E K I N H O S P I T A L A U X I L I A R YAPPLICATION FOR FINANCIAL ASSISTANCEPLEASE PRINT OR TYPE. You may use the reverse side of the application for additional information if necessary.I.GENERAL INFORMATIONA.Full Name _B.Present Address _Telephone _C.Permanent Address _Telephone _D.Social Security Number _E.Marital Status (please circle):SingleEngagedMarriedDivorcedSeparatedWidowF.Dependents (Give name, age, relationship)_G.Who is primary contributor(s) to your support? _ Relationship _H.Are you employed?Yes_No_If yes, where? _Part-time or full-time _Approx. Annual Income: $_Occupation _II.INFORMATION REGARDING FAMILY (ANSWER AREAS APPLICABLE TO YOU)A.Spouses name _Place of employment _Occupation _Approx. Annual Gross Income: $_ B.Number and ages of your dependent children: _C.Do you contribute to the support of any other person(s) or have any significantfinancial obligations? Please describe: _If you are claimed as a dependent by your parent(s), please complete D, E, and F.D.Fathers name _Place of employment _Occupation _Approx. Annual Gross Income: $_E.Mothers name _Place of employment _Occupation _Approx. Annual Gross Income: $_F.Number and ages of brothers and sisters who are dependent children: _Are any attending school?Yes_ No_Where? _III.EDUCATIONAL INFORMATIONA.In what course of study are you enrolled? _B.In what school are you enrolled? _Address:_C.Will you be attending school on a full or part-time basis? _Anticipated hours per term: _D.If you will be attending part-time, detail specifically what else you will be doing:_E.Residence plans while attending school? _F.What is your professional goal? _G.Number of years required for completion of your course of study? _H.Anticipated graduation date? _I.Describe the qualities you feel you have that are significant to your field of study: _J.Where do you intend to practice your profession? _K.High school from which you graduated? _Year? _Counselor? _L.Have you done post-high school study in any other field? _If you answered yes, to what do you attribute your change in your area of study? _M.Describe any experience you have had in a health or science-related field, either through employment or in a volunteer capacity: _N.What honors have you received and when? _O.List any pertinent jobs you have held: _P.List below any special needs and costs in addition to tuition, room and board, and textbook expenses that you anticipate this year:_Q.List awards/scholarships you have received for your hospital-related career training.Award/ScholarshipAmountYear_R.How did you become aware of this scholarship fund? _Please submit your most recent high school and/or college transcript with your application, verification of income (W-2), and two letters of reference-one personal (excluding relatives) and one from a teacher, counselor or employer. All pertinent information must be delivered to Pekin Hospitals Volunteer Services Department no later than 4:30 p.m. on Friday, April 14, 2017. We will not be responsible for applications delivered to any other department in the hospital. If sending by mail, all pertinent information must be received by the Volunteer Services Department post-marked no latert han April 14, 2017.Pekin HospitalVolunteer Services600 S. 13th StreetPekin, IL 61554All information on this application is, to the best of my knowledge, complete and valid. I give this information for the purpose of obtaining financial assistance, and authorize the verification of any information made herein._Signature of ApplicantSignature of parent, guardian or spouse_DateDateAuxil/scholars/scholarship application