All information submitted with this application is confidential. Please print or type. If you need additional space, please write on plain white 8 ½ x 11 paper and attach to application.

PERSONAL DATA

Name__________________________________________Birthdate_________________

Social Security Number________________________

Current Address__________________________________________________________

City______________________________ State _____________ Zip________________

Phone ___________________ Cell______________________ Fax_________________

Email address: ___________________________________________

Father’s Name____________________________________________________________

Address _____________________________________________Phone______________

City_____________________________ State______________ Zip_________________

Mother’s Name___________________________________________________________

 Check if same as father’s address.

Address _____________________________________________Phone______________

City____________________________State_________________Zip________________

EDUCATIONAL BACKGROUND

Name of high school_______________________________________________________

Address_________________________________________________________________

City____________________ State_______ Zip_____________ Phone_______________

SCHOOL ACTIVITIES/ AWARDS

Please list awards, honors, scholarships received and activities participated in for the last 2 years. Prior years may be listed on a separate sheet of paper.

________________________________________________________________________

________________________________________________________________________

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Other activities and offices held (High school, community clubs)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

WORK EXPERIENCE (other than volunteer)

List all work experience in which you have participated, whether related to health care or not.

Employer Job Title or Duties Dates

______________________ ____________________________ _________________

______________________ ____________________________ _________________

______________________ ____________________________ _________________

PROFILE OF THE APPLICANT (Educational and Career Goals)

Scholastic standing: GPA _______________

Name of school planning to attend in the fall ___________________________________

Major__________________ Minor area of specialization _________________________

What health career do you plan to pursue?

________________________________________________________________________

________________________________________________________________________

What qualifications do you feel you have to pursue a health care career (100 words or less).

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Education and occupational goals as they relate to the health care industry (100 words or less).

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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VOLUNTEER ACTIVITIES/ SERVICES

Community Volunteer Services:______________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Name of agency or institution________________________________________________

Supervisor____________________ Address ________________________________

Phone _______________________ Fax _______________

Total hours________________________ Hours during last 2 years _________________

Name of agency or institution________________________________________________

Supervisor____________________ Address ________________________________

Phone _______________________ Fax ______________

Total hours________________________ Hours during last 2 years _________________

Name of agency or institution________________________________________________

Supervisor____________________ Address ________________________________

Phone _______________________ Fax ______________

Total hours________________________ Hours during last 2 years _________________

The applicant hereby consents that the Scholarship Selection Committee be fully informed as to the Applicant’s scholastic standing, character, and other factors having a bearing on this application.

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(Signature of Applicant)

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(Date completed)

Please note: It is the applicant’s sole responsibility to see that the completed application, official transcripts, and letters of recommendation are received by Fitzgibbon Hospital Scholarship Committee by March 16, 2007.