Irv Hoffman SHL Nursing Scholarship App

lrv Hoffman Silver Haired Legislature Nursing Scholarship Application

A $1,000 scholarship is a onetime scholarship for students in professional nursing programs who are interested in nursing older adults. Monies for the scholarship are donated by the Kansas Silver Haired Legislature (SHL). The scholarship recipient is selected by a committee from the Silver Haired Legislature.

The completed application and essay must be postmarked or received by email no later than August 31. The winner will be notified and funds will be awarded by September 20.

Send to:

Eligibility Criteria:

• Must be a resident of Kansas Must be a US citizen
• Must be enrolled full-time in nursing courses at a nationally accredited Kansas college or university

* Must agree to work two (2) years with older adults as a Registered Nurse after graduation and passing state boards

Application Instructions:

• Type or print on application form
• Write an essay entitled: “How I Can Contribute to the Care of Older Adults” Submit a current resume

Essay Directions:

• Type and double space
• Use appropriate grammar and sentence structure
• Must be a 500 word original composition with your ideas and may include references.

Irv Hoffinan Silver Haired Legislature Nursing Scholarship Application Form

Section A: Identification Information

Last Name: ______________  First Name: ______________   MI ______

Maiden Name:________________

Street Address:________________

City: ___________________________________

State: __________________________________

Zip Code: _______________________________

Home Phone Number: ___________________  Alternate/Cell  Number:___________________

E-Mail Address: _______________________  Are you a resident of Kansas? ________________

Are you a US citizen? ___  Are you enrolled full time in a Kansas Nursing Program? ______________

Name of Nursing Program _____________________________________________________

Applicants Signature ____________________________________ Date _________________

Section B: Certification and Release of Information

Applicant: Sign and date the certification and the authorization for release of information. I affirm that the information reported is complete, accurate, and true to the best of my knowledge.

I have authorized Nurse Administrator, Director, Chair or Dean of the Nursing Program to release the information requested for the purpose of determining eligibility for the Silver Haired Legislature Scholarship.

I understand that the application and essay must be postmarked or received by email no later than July 31. Applications postmarked or received by email after July 31, will not be accepted.

Applicant Signature _______________________________ Date _______________________

Student Status Verification  Release of Information Form

Applicant, please sign and give to the Nurse Administrator, Director, Chair or Dean of your nursing program.

Applicant Last Name __________________ First Name _______________________________

I authorize school officials to release the information requested to Eileen Hawkins, Silver Haired Legislature, for the purpose of determining eligibility for a Silver Haired Legislature Nursing Scholarship.

Signature __________________________________________ Date ___________________

Student Status Verification

Completed by the Nursing Program

Nurse Administrator, Director Chair or Dean of the nursing program: Please complete this page and mail or email to:

Student Name _________________________

School/Program Name ______________________________________________________

Name of Program Administrator _______________________________

Student’s beginning date in nursing program: ______________________

Student’s expected completion date for nursing program: ________________

Please indicate program type: BSN ________________ ADN ________________

The professional nursing program student: In good standing? Yes________ No________

Student is full time? Yes _______ No ________  Student is a resident of Kansas. Yes ____  No ____

Program Administrator’s Signature _________________________ Date ________________