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NURSING CARLE FOUNDATION SCHOLARS

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					CARLE FOUNDATION
SCHOLARS @ PARKLAND

HEALTH CAREERS
SCHOLARSHIP PROGRAM


Checklist for Applying:


      Scholarship Program Application

      Statement of Academic & Professional Goals

      Minimum of 3 References

      All Official & Complete Transcripts




                                                   Updated January 07
                    CARLE FOUNDATION SCHOLARS @ PARKLAND
                     HEALTH CAREERS SCHOLARSHIP PROGRAM
The Carle Scholars program gives financial assistance for educational expenses to students enrolled
in the following health careers programs at Parkland College: EMT – Paramedic, Nursing,
Occupational Therapy, Radiology, Respiratory, and Surgical Technology. Students may apply for an
initial installment of $2,500 per academic year, and an additional application may be submitted for a
total assistance amount of $5,000.

To qualify, you must:

   Be currently enrolled at Parkland College
   Have a cumulative high school or college G.P.A. of 2.75 or above on a 4.00 scale. Strong
    consideration will be given to academic performance in the Sciences.

To apply:

   Complete and return the scholarship program application and statement of academic and
    professional goals to the Health Professions Office at Parkland College.
   Attach a current copy of official high school or college transcripts.
   Provide 3 employment references from previous and current employers. If not previously
    employed, academic references from high school or college instructors may be accepted.

After receipt of all required information, the Health Careers Scholars Selection Committee will review
your application.

General Information:

1. Initial Scholar’s may not exceed $2,500.00.

2. Scholarship monies will be disbursed from Parkland College Foundation in accordance with their
   policies and protocols.

3. Those students submitting applications within 1 year of graduation from their healthcare program
   will be scheduled for a pre-placement interview with a recruiter from The Carle Foundation. The
   Carle Foundation will contact the applicant to set up the interview time.

4. Candidates may reapply for additional assistance. Reapplication may be made for up to an
   additional $2,500 for a total of $5,000 in financial assistance.


If you would like further clarification contact:

                       Bobbi Scholze, Health Professions Department Chair
                                        Parkland College
                                    2400 W. Bradley Avenue
                                      Champaign, IL 61821
                                (217) 351-2681 or (217) 351-2224




                                                                                              Updated January 07
                                                           CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                          HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM
                                                                        APPLICATION


                                                                                  Date of Application
    (PLEASE PRINT)


    Name                                                                          Student ID. #
                           (Last)               (First)             (Middle)
    Present
    Address                                                                       Telephone No.        (     )       -
    Permanent
    Address                                                                       Telephone No.        (     )       -
    E-mail
    Address                                                                       Cell Phone (         )         -

    Degree: (circle one)            EMT - PARAMEDIC               NURSING           OCCUPATIONAL THERAPY
                                                                                  ASSISTANT
                                       RADIOLOGY                RESPIRATORY         SURGICAL TECHNOLOGY

    Expected Graduation Date

    Cumulative GPA                          Date GPA Calculated                   School Grade Point Scale: 4.0                  5.0
                                                                                                                         (circle one)

EDUCATION/SKILLS

School               Name of School         Dates Attended       Years         Course of            Did You                  Degree or
                      City and State          From To          Completed        Study              Graduate?                  Diploma
                                                                                                  (Please circle)
 High
School                                                                                            Yes / No


College                                                                                           Yes / No



College                                                                                           Yes / No



Other                                                                                             Yes / No




ACADEMIC REFERENCES (List 4 references who are teachers, instructors, or (former) employers)

                            Name                          Company/School and         Present Title                   Phone No.
                                                               Address

1
2
3
4
                                                                                                                              Updated January 07
Have you received financial assistance with an employment commitment from another employer? Yes No

EMPLOYMENT HISTORY List both part-time and full-time jobs. Start with present or last job (include military experience). Use
additional sheets if necessary



Name of Employer                                                  Supervisor’s Name

Address                                                           Your Job Title

Phone     (      )               -                                Duties:

Dates of Employment


Name of Employer                                                  Supervisor’s Name

Address                                                           Your Job Title

Phone     (      )               -                                Duties:

Dates of Employment


Name of Employer                                                  Supervisor’s Name

Address                                                           Your Job Title

Phone     (      )               -                                Duties:

Dates of Employment

Are you legally eligible for employment in the United States? Yes No

Please reread this application carefully. Failure to complete all areas will delay processing of this application.

I understand that I am applying for financial assistance for my health career education through Carle Foundation Hospital,
Urbana, Illinois. I affirm that all information I have provided in this application is accurate and correct. Further, I
understand that any false statements made, as part of this application will be considered sufficient cause for denial of
financial assistance from Carle Foundation Hospital. I authorize Parkland College to release any and all academic and
financial aid information to Carle Foundation Hospital. I also grant permission for the authorities of Carle Foundation
Hospital to investigate my references and release said Hospital from any and all liability resulting from such investigation.


Candidate’s Signature ______________________________________________ Date ___________________________


                                                             APPROVAL _________________________________________
                                                                            Chair – Health Careers Committee          Date


                                                             APPROVAL _________________________________________
                                                                            Manager – Human Resources                 Date
                                                                            Carle Foundation Hospital


                                                                                                                       Updated January 07
                                                       CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                      HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM




Student: ________________________________________________________________


                   Brief Statement of Academic and Professional Goals
                                        (Please limit to one typewritten page)




                                                                                       Updated January 07
                                                   CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                  HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM
                                                  REQUEST FOR ACADEMIC REFERENCE

                                                                       Parkland College
                                                                    2400 W. Bradley Avenue
                                                                     Champaign, IL 61821
                                                                         (217) 351-2383



TO BE COMPLETED BY STUDENT:

Name __________________________________________ ID # ____________________________

Address _________________________________________________________________________

         _____________________________________________Telephone _(___)____-__________

College/School ___________________________________________________________________

Address _________________________________________________________________________

Telephone _(____)_____-__________

Expected Date of Graduation _____________ Expected Degree ____________________________
                                   (Month/Year)


Name of instructor providing reference ____________________________________________
                                                   (Please Print)




I grant permission for Carle Foundation Hospital to investigate my references and release said
hospital and my (former) instructor from any and all liabilities resulting from such investigation.




__________________________________________________                         ___________________________
                      Applicant’s Signature                                                  Date




                                                                                                    Updated January 07
                                                           CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                          HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM
                                                        REQUEST FOR ACADEMIC REFERENCE


To Be Completed by Instructor:
Student ____________________________________________________________________________________________________

For which class or clinical rotation were you this student’s instructor? ____________________________________________________

Semester/year of class/clinical: __________________________________________________________________________________

Professional Qualities                                  Exceptional   Above Average   Average       Below Average        N/A
Academic Achievement
Attendance-reports to class on-time and prepared.
Development Potential
Has potential for personal and professional growth.
Leadership
Ability to assume responsibility, organize work and
execute projects with others.

Problem Solving Ability/Judgement
Critically evaluates facts and uses common sense
to reach a reasonable solution.

Is able to interpret observations and take
appropriate actions.
Seeks guidance from resource people.
Attitude/Adaptability
Adapts to changes in the working environment and
adjusts without adverse reaction.
Organization
Coordinates work in a logical fashion. Expedites
plan in a reasonable length of time.
Adapts to unexpected change in plans.
Initiative/Motivation
Creativity
Demonstrates resourcefulness. Uses imagination;
is not stereotyped in thinking.
Communication Skills
Communicates clearly both orally and in writing.
Uses tact when communicating. Listens attentively.
Ethics and Professionalism
Conducts oneself in an ethical and professional
manner when relating to co-workers, patients and
the public.
Establishes effective interpersonal relationship with
patients, families and co-workers.

COMMENTS: (May be completed on separate page if desired)



Signature ____________________________________________ Title _______________________________ Date ______________
                            (Instructor’s Signature)
I may be contacted at _______________________________ for further information.
                                       (Phone Number)




                                                                                                                  Updated January 07
                                                  CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                 HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM
                                              REQUEST FOR EMPLOYMENT REFERENCE

                                                               Parkland College
                                                           2400 W. Bradley Avenue
                                                            Champaign, IL 61821
                                                               (217) 351-2383



TO BE COMPLETED BY STUDENT:

Name __________________________________________ SS# ____________________________

Address _________________________________________________________________________

         _____________________________________________Telephone _(____)____-_________

Place of Employment_______________________________________________________________

Address _________________________________________________________________________

Telephone _(____)____-_________

Dates of Employment: From: ______/_______ To:______/__________
                                  (Month/Year)          (Month/Year)




I grant permission for Carle Foundation Hospital to investigate my references and release said
hospital and my (former) employer from any and all liabilities resulting from such investigation.




__________________________________________________                     ___________________________
                      Applicant’s Signature                                         Date




                                                                                               Updated January 07
                                                        CARLE FOUNDATION SCHOLARS @ PARKLAND
                                                       HEALTH CAREERS SCHOLARSHIP LOAN PROGRAM
                                                  REQUEST FOR EMPLOYMENT REFERENCE


TO BE COMPLETED BY STUDENT:

Name:
Social Security Number:                  -             -
Place of Employment:
Employment Dates:             From:                /              To:          /
                                             (Month/Year)                   (Month/Year)

Job Title:


TO BE COMPLETED BY EMPLOYER:

Is the above information correct? Yes            No         If not, please list corrected information

Reason for leaving:___________________________________________________________
__________________________________________________
Please rate him/her on the characteristics described below:
                                                       Poor        Fair       Avg.         Good    Very
                                                                                                   Good

  Attendance
  Ability to Work with Others
  Job Knowledge
  Quantity of Work
  Quality of Work
  Overall Performance

Eligible for rehire?        Explanation _____________________________________________

Additional Comments: ___________________________________________________________
____________________________________________________
Respondents Name:                                                    Date:_______/_____/_____

I may be contacted at _______________________________ for further information.
                                      (Phone Number)



                                                                                                          Updated January 07
                                               Carle Foundation Scholars @ Parkland
                                              Health Careers Scholarship Loan Program
                                                     Assessment/Approval Form

Applicant Name: (Last) ______________________________________ (First) _______________________________

Degree: (circle one)   EMT – PARAMEDIC          NURSING             OCCUPATIONAL THERAPY

                       RADIOLOGY                RESPIRATORY         SURGICAL TECHNOLOGY

Graduation Date: (Month) _____ (Year) _______


Check when complete.

____   Application, original submission date __________, comments: _______________________________________

____   Statement of Academic and Professional Goals, comments: __________________________________________

____   References (circle as turned in): Employment 1, 2, 3; Academic 1, 2, 3;

____   Transcript: High School GPA _______; College GPA ________

Packet Completion Date: ______________________


Parkland Assessment: (circle one)    HIGHLY RECOMMEND             RECOMMEND           DO NOT RECOMMEND

Comments (Required for Highly Recommend or Do Not Recommend Ratings) ____________________________________________

________________________________________________________________________________________________


Parkland Representative Signature ___________________________________ Title ______________Date___/___/____



Carle Foundation Assessment:(circle one) HIGHLY RECOMMEND           RECOMMEND          DO NOT RECOMMEND

Comments (Required for Highly Recommend or Do Not Recommend Ratings) ____________________________________________

________________________________________________________________________________________________


Carle Representative Signature ______________________________________ Title ______________Date___/___/____



Carle Foundation Approval: (circle one)    APPROVED         APPROVED WITH STIPULATION             DENIED

Comments _______________________________________________________________________________________

________________________________________________________________________________________________


Carle Approval Signature ___________________________________________ Title ______________Date___/___/____



                                                                                                        Updated January 07
                                              Some                                                       Clearly              Insert
                      Unsatisfactory       Deficiencies        Satisfactory        Exceptional         Outstanding            Rating
                                             Evident
                             1                   2                   3                   4                   5                   1 to 5
     TRAITS                                                                                                                  U=Unable
                                                                                                                                to
                                                                                                                             evaluate

 G.P.A. (fill in)
                                                                                                                            P
     G.P.A.                <2.75                2.75            2.76 – 3.00         3.01 – 3.75           >3.751

 G.P.A., Parkland
   Comments

   G.P.A., Carle
    Comments

                                                                                                                             P
                       Inconsistent,
                                           Inconsistent,
                      multiple “W”, “I”                        Inconsistent,        Consistent,
   Academic                               multiple “W”, “I”                                           Consistent, No
                          +/or “N”                            “W”, “I” +/or “N”   “W”, “I” +/or “N”
    History                                   +/or “N”                                                “W”, “I” or “N”
                       unaccounted                             accounted for       accounted for
                                          accounted for
                             for
 Academic History,
Parkland Comments

 Academic History,
  Carle Comments
                                                                                                                             P
                      Below average                                               Above average       Superior ratings
  Academic                                  Any below         Overall average
                        ratings in                                                  ratings in          in multiple
  References                              average rating          ratings
                      multiple areas                                              multiple areas           areas
     Academic
    References
Parkland, Comments
     Academic
 References Carle,
     Comments
                                                                                                                             P
                       Inconsistent,
                                           Inconsistent,        Consistent,                           Consistent, no
  Employment           multiple gaps                                              Consistent, no
                                          gaps accounted      gaps accounted                          gaps, relevant
    History            unaccounted                                                    gaps
                                                for                 for                                 to degree
                            for
   Employment
 History, Parkland
    Comments
   Employment
   History, Carle
    Comments
                                                                                                                             P
                      Poor in multiple    Any poor rating     Overall average     Good ratings in      Very good
  Employment
                          areas           or multiple fair        ratings         multiple areas       ratings in
  References
                                              ratings                                                 multiple areas
   Employment
    References,
Parkland Comments
   Employment
 References, Carle
    Comments
                                                                                                                             P
                                                                                                          Clearly
                                                                                                        articulated,
  Professional           Unable to                                                                    consistent with
                                                                Articulated
     Goals               articulate                                                                   academic and
                                                                                                       employment
                                                                                                          history
Professional Goals,
Parkland Comments

Professional Goals,
 Carle Comments


                                                                                                                         Updated January 07

				
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