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 July 31, 2018. The winner will be notified and funds will be awarded by September 1, 2018.
APRN 13413 W Links Ct.
Wichita, KS 67235
Or email: firstname.lastname@example.org
- 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
- Type or print on application form
- Write an essay entitled: “How I Can Contribute to the Care of Older Adults” Submit a current resume
- 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 ______
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, 2018. Applications postmarked or received by email after July 31, 2018 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:
Eileen Hawkins, 13413 W Links Ct. Wichita, KS 67235.
Email: meileenl329 @hotmail.com
All scholarship related information must be postmarked or received by email no later than July 31, 2018.
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 ________________