" " Andalusia Health Services Scholarship Application

Andalusia Health Services Scholarship

January 31, 2019


P. O. BOX 56 – ANDALUSIA, AL  36420   334-488-5990


Full Name _________________________________________________________________________

Home Address ______________________________________________________________________

Social Security Number _______________________________

High School(s) Attended and Graduation Date _______________________________________________

College (s) Attended ____________________________________________________________________

Check appropriate field of study:  Medicine ___, Nurse Practitioner ___, Registered Nursing ___,

Licensed Practical Nursing ___, Lab Technology  ___, Occupational Therapy ___, Occupational Therapy

Assistant ___,  Paramedic ___, EMT___, Physical Therapy ___. Physical Therapy Assistant ___,

Radiology Technology /Imaging___,  Speech Pathology (Masters) ___, Surgical Technology___, Diagnostic Medical Sonography ___, Pharmacy ___.

College/University you will attend in 2019 __________________________________________________

Have you been admitted to the program indicated? _____  If yes, include proof with your application.  If no, when will you be notified?  _______________Semester for scholarship to begin: Fall 2019 ___,  Spring 2020 ___.

Final Semester and year for scholarship: ______________ Total number of semesters   _____.

TRANSCRIPTS:  Applicants must submit high school and college transcripts.

NARRATIVE:  Applicants must write a brief narrative indicating the reason(s) for applying for a scholarship, career plans, and previous accomplishments and honors.

EVALUATIONS:  Applicants must have two (2) evaluations submitted following the instructions on the evaluation sheet.

Completed applications, transcripts, narratives and evaluations must be received by March 31, 2019, at P. O. Box 56, Andalusia, AL  36420.  By April 7, you should be informed that your application was received.  You may verify that your completed application was received by calling 334-488-5990.

Your signature below indicates that you are a Covington County resident and that the information provided is accurate to the best of your knowledge.  It further indicates that if awarded a scholarship and you do not complete your degree and return to Covington County and work in the health field in which you were approved for a scholarship, you will repay the funds received plus interest.  In addition, it indicates that you agree for your evaluation forms to remain confidential and unavailable for review by yourself or any other party.

Signature ___________________________________________________________ Date _____________