OZARKS MEDICAL CENTER SCHOLARSHIP PROGRAM

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1 Overview: To establish a scholarship for students pursuing careers in nursing and the allied health care professions. The purpose is to attract new recruits to health care and assist current students in registered and licensed health care programs, resulting in employment at Ozarks Medical Center. The deadline for all applications will be July 1, Applicants will compete for scholarships based on the priority of job-specific vacancies within the Ozarks Medical Center health care system. Applicants applying for the scholarships will receive letters of acceptance, as an alternate, or denial of scholarship by August 1, The program will be monitored by the Human Resources Recruitment Manager. The administration of the scholarship will consist of monitoring the students GPA and verification of good standing. Eligibility for Scholarship: 1. Show evidence of acceptance to an academic program leading to eligibility for licensure/registration from an accredited and licensed institution for nursing or allied health care. 2. Complete all required application information, including official school transcripts and references by application deadline. Late or incomplete applications will not be reviewed by the committee. 3. Show a minimum of a 2.75 grade point average each semester, on a 4.0 scale for high school or post-secondary educational course work. This is a non-weighted grade point average, (a lower semester grade cannot be added to a higher semester grade to meet the 2.75 grade point average). 4. Provide evidence of continued enrollment in good standing in the same academic program. This must be provided before the second year of funding. 5. Pursue a curriculum that will allow graduation requirements to be fulfilled within two (2) years of the initial scholarship payment. Eligible Professions: 1. Registered Nurse (RN) 2. Licensed Practical Nurse (LPN) 3. Certified Registered Nurse Anesthetist (CRNA) 4. Pharmacist (Pharm. D.) 5. Registered Radiologic Technology disciplines 6. Nuclear Medicine Technology disciplines 7. Speech Language Pathology 8. Occupational Therapy/Occupational Therapy Assistant 9. Physical Therapy/Physical Therapy Assistant 10. Medical Technologist 11. Other Profession: 1

2 Scholarship Amount: A recipient is eligible to receive maximum funding of $5,000 per academic year with total funding not to exceed $10,000. Scholarships are automatically renewed for a maximum of two (2) years upon verification of continued enrollment, required GPA, and in good standing. The academic year will consist of fall, spring, and summer. Obligations for Receiving OMC Scholarship: One calendar year of OMC s defined full-time employment is required for each academic year of scholarship awarded. We will place you in your professional area. Work repayment must take place in OMC s system where job openings are available. If Ozarks Medical Center does not have a position open in which to place the recipient to fulfill their work repayment within six (6) months of graduation, the full scholarship amount will be forgiven. Declining an available work position, failure to complete the academic program or failure to complete the entire work agreement will require immediate payment of the full scholarship amount awarded. If the full scholarship amount is not repaid immediately, then interest will accrue at an interest rate equal to the prime lending rate as published in the Wall Street Journal, upon date of denial, plus two percent. The interest will be compounded monthly at a rate to be adjusted quarterly. Default in repayment will result in collection efforts including garnishment of future wages. How to Apply: Application forms are available at Ozarks Medical Center, Human Resources Department if able print out this form, fill out and return to the Human Resources Department. 2

3 Application Checklist () COMPLETE COMPONENTS All sections of the two-page application completed Enrollment section completed and signed by a school representative Application signed and dated Personal statement enclosed reflecting personal reason(s) for choosing health care as a profession, including professional goals Extracurricular, community, or health care activities provided Two, two-page reference forms enclosed in sealed envelopes, with the envelope flap signed by the reference High school transcript or general equivalency diploma (GED) enclosed, OR Institution has agreed to submit transcript in a separate mailing Post-secondary transcript(s) enclosed, OR Institution has agreed to submit transcript in a separate mailing It is the applicant s responsibility to ensure that all components of the Ozarks Medical Center Scholarship application are complete. This checklist is provided to assist the applicant. Failure to submit a complete application will result in the application being deemed ineligible. Sign, date, and return the complete checklist with the application. Printed Name of Applicant Applicant Signature Date 3

4 Application Form The nursing and allied health scholarship program is a competitive process. All eligible applications will be evaluated. All eligible applications may not receive funding. It is the applicant s responsibility to ensure that all components of the application are complete. Please refer to the Application Checklist. All information is confidential and for programmatic purposes only. Please type or print. PROGRAM TYPE Indicate the program in which you are enrolled or to which you have been accepted. Registered Nurse (RN) Licensed Practical Nurse (LPN) Nurse Anesthetist (CRNA) Pharmacist (Pharm.D) Registered Radiologic Technology Nuclear Medicine Technology Respiratory Therapy Speech Language Pathology Occupational Therapy Physical Therapy Paramedic Other. APPLICANT INFORMATION Name (Last, First, Middle Initial) Social Security Number Maiden Name/Other Names Used Current Mailing Address (Street) City Telephone State ZIP address Permanent Mailing Address (Street) Telephone City State ZIP EDUCATION Please submit an original transcript with this application for each secondary and post-secondary academic institution attended. Note: If you have a GED, include the original transcript with signature. Circle the highest grade completed: GED College High School Attended and Location Graduation Date College/University Attended and Location Dates Attended Hours Graduation Date Degree Earned College/University Attended and Location Dates Attended Hours Graduation Date Degree Earned If additional space is needed, please attach a separate sheet. ENROLLMENT This section is to be completed and signed by a representative of the health profession program of acceptance. Name of Institution Address Tuition Semester / Year Name of Contact Person Title of Contact Person Telephone $ Term Academic Fees Semester / Year $ Term Academic Year Applied For Student s Current Year in the Program Program Start Date Projected Graduation Date I certify that the applicant is enrolled and in good standing or has been accepted for enrollment. Additional information deemed necessary will be provided to Ozarks Medical Center upon request. Signature of School Representative School or Notary Stamp Title Date 4

5 ABILITY TO RESIDE IN MISSOURI TO FULFILL WORK REPAYMENT Are you eligible to work in Missouri two years following graduation for work repayment? Yes No CLOSEST LIVING RELATIVE RESIDING IN THE UNITED STATES BUT NOT IN THE HOME (If none, a United States contact) Name (Last, First, Middle Initial) Relationship Telephone Street City State ZIP EMPLOYMENT Are you currently employed? Start Date Yes No If yes, name and address of employer May we contact you at work? Work Phone Yes No Do you plan to remain with this employer? Yes No COMMITMENT TO PRACTICE Note: Scholarships will be selected for those students willing to work in Ozarks Medical Center health system. Are you willing to fulfill your work repayment obligation in an area of Ozarks Medical Center other than your first choice? Yes No N/A PERSONAL STATEMENT AND ADDITIONAL INFORMATION On the attached page, submit a personal statement describing your commitment to provide heath care at Ozarks Medical Center. This statement is not to exceed one single-spaced typewritten page. The personal statement should reflect your personal reason(s) for choosing health care as a profession, including your professional goals. On the attached page, submit extracurricular, community, or healthcare activities. Indicate the scope of each activity and your level of participation. Note: It is important for the selection committee to have this information from all applicants. How did you know about the Ozarks Medical Center Scholarship Program? Hospital School Web Newspaper Other, please specify APPLICANT Submit the completed application to Ozarks Medical Center, Human Resources Department or mail to Ozarks Medical Center Scholarship Program, Human Resources department, P.O. Box 1100, West Plains, MO The deadline for all applications is July 1, Failure to submit a complete application will result in the application being deemed ineligible. Questions regarding the application and selection process should be directed to the Ozarks Medical Center, Human Resources department at (417) I certify that the information contained in this application is true, complete, and correct to the best of my knowledge and that all funds will be used for tuition expenses and academic fees in the current academic year. I hereby authorize the release of personal, scholastic, and financial information related to my educational status from any academic institution I have attended in the past, am currently enrolled, or may be enrolled as a student in the future, to Ozarks Medical Center. Signature of Applicant Date 5

6 Personal Statement Form Submit a personal statement below describing your commitment to provide health care at Ozarks Medical Center. This statement is not to exceed one single-spaced typewritten page. The personal statement should reflect your personal reason(s) for choosing health care as a profession, including your professional goals. 6

7 Extracurricular, Community, or Healthcare Activities Form List extracurricular, community, or health care activities below. Indicate the scope of each activity and your level of participation. Note: It is important for the selection committee to have this information from all applicants. 7

8 Reference Form Page 1 of 2 I. TO BE COMPLETED BY APPLICANT Please use this form for submitting your references. Two references are required, including at least one reference from an instructor or an employer/supervisor. References should not include family members. If you are a current OMC employee, a reference must be provided by your immediate supervisor. Please remind your references to return this form to you as soon as possible. The application deadline for all applications is July 1, 2018 no later than 4:00 p.m. CDT. Complete this portion of the form and then provide it to your reference for completion and return to you. You may want to provide your reference with a self-addressed envelope. Enclose the sealed envelope with your application. Printed Applicant Name Social Security Number Printed Name of Reference Reference Address City State ZIP Telephone II. RELEASE OF ACCESS TO THIS LETTER OF RECOMMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L (Family Educator Rights and Privacy Act of 1974). I waive my right to access this letter of recommendation. I do not waive my right to access this letter of recommendation. Signature of Applicant III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for person making the recommendation: Review sections I and II to ensure the applicant has provided the necessary information. Complete the remainder of the form. Place the completed recommendation in an envelope, seal, and sign your name across the seal of the envelope. Return the form to the applicant. How well do you know the applicant? Very well Fairly well Minimally Unknown How long have you known the applicant? Identify the associations you have had with the applicant. Check all that apply. Instructor Community Organization Employer/Supervisor Academic Advisor Friend Other OZARKS MEDICAL CENTER SCHOLARSHIP PROGRAM 8

9 Reference Form Page 2 of 2 Name of Applicant Please rate the applicant s achievement and potential by entering an X in the appropriate spaces below. Above Below Skill Exceptional Decision-making ability Organizational skills Communication skills: Written Oral Adaptability to stress Positive attitude Integrity Interpersonal sensitivity Leadership ability Ability to commit to: A goal Persons Not Able to Respond In addition to the ratings, please give your evaluation of the applicant. You may want to indicate your perceptions of the applicant s strengths and limitations. My recommendation is: highly recommend recommend do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number OZARKS MEDICAL CENTER SCHOLARSHIP PROGRAM 9

10 Reference Form Page 1 of 2 I. TO BE COMPLETED BY APPLICANT Please use this form for submitting your references. Two references are required, including at least one reference from an instructor or an employer/supervisor. References should not include family members. If you are a current OMC employee, a reference must be provided by your immediate supervisor. Please remind your references to return this form to you as soon as possible. The application deadline for all applications is July 1, 2018 no later than 4:00 p.m. CDT. Complete this portion of the form and then provide it to your reference for completion and return to you. You may want to provide your reference with a self-addressed envelope. Enclose the sealed envelope with your application. Printed Applicant Name Social Security Number Printed Name of Reference Reference Address City State ZIP Telephone II. RELEASE OF ACCESS TO THIS LETTER OF RECOMMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L (Family Educator Rights and Privacy Act of 1974). I waive my right to access this letter of recommendation. I do not waive my right to access this letter of recommendation. Signature of Applicant III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for person making the recommendation: Review sections I and II to ensure the applicant has provided the necessary information. Complete the remainder of the form. Place the completed recommendation in an envelope, seal, and sign your name across the seal of the envelope. Return the form to the applicant. How well do you know the applicant? Very well Fairly well Minimally Unknown How long have you known the applicant? Identify the associations you have had with the applicant. Check all that apply. Instructor Community Organization Employer/Supervisor Academic Advisor Friend Other 10

11 Name of Applicant OZARKS MEDICAL CENTER SCHOLARSHIP PROGRAM Reference Form Page 2 of 2 Please rate the applicant s achievement and potential by entering an X in the appropriate spaces below. Above Below Skill Exceptional Decision-making ability Organizational skills Communication skills: Written Oral Adaptability to stress Positive attitude Integrity Interpersonal sensitivity Leadership ability Ability to commit to: A goal Persons Not Able to Respond In addition to the ratings, please give your evaluation of the applicant. You may want to indicate your perceptions of the applicant s strengths and limitations. My recommendation is: highly recommend recommend do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number 11

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