HEALTH CARE PROFESSIONS SCHOLARSHIP PROGRAM
Guidelines and Application
The Alexander Eastman Foundation Health Professions Scholarship Program is for students pursuing postsecondary education or training in a health care field. Consideration for scholarships is based on merit and
need. The program is designed to provide scholarship grants to health care workers who seek to utilize new
equipment and medical techniques, improve knowledge in a specific health care area, or add to professional
qualifications to increase job security or career advancement. Scholarships range in size from $500 to $2,500.
ELIGIBILITY
Eligible applicants to the program must:


Currently practice health-care skills or work in health-service organization in: Derry, Londonderry,
Windham, Sandown, East Hampstead, Hampstead, or Chester.
OR
Be a resident of Derry, Londonderry, Windham, Sandown, East Hampstead, Hampstead, or Chester AND
currently practice health care skills or work in health-service organizations in one of the following towns:
Derry, Londonderry, Windham, Sandown, East Hampstead, Hampstead, Chester, Atkinson, Auburn, Salem,
or Pelham.

Be entering or enrolled in a full-time, part-time or short-term program of study in a health field including,
but not limited to: medicine, dentistry, nursing, medical laboratory, radiology, pharmacology,
rehabilitation therapy, nutrition, health care administration, or home health care.

Be an independent student (over age 24 or have others dependent on you).

Understand and agree to adhere to the above mentioned residency/employment guidelines for at least 18
months after receipt of the award.
WHEN TO APPLY
Applications received by June 17 will be considered. No late applications will be considered.
HOW TO APPLY
Download the application from the web site and complete all sections. Please email the application and
attachments to bmcnamara@alexandereastman.org or mail paper copies to:
Alexander Eastman Foundation
75 South Main Street, Unit 7 PMB 250, Concord, NH 03301
To request an e-mailed or paper copy of the application, please call Betsy McNamara at 1-888-228-1821 x81
(toll free), or e-mail bmcnamara@alexandereastman.org.
ALEXANDER EASTMAN FOUNDATION HEALTH CARE PROFESSIONS SCHOLARSHIP PROGRAM APPLICATION
Applications must be received by June 17 by mail or electronically. Applicants must submit applications and
attachments either all in electronic form or all in paper form – the format may not be mixed. All applicants will
receive a written or e-mailed confirmation of receipt.
PERSONAL
Name (First Name, Middle Initial, Last Name):
Address:
Daytime Phone Number:
Email:
Birth date:
School for which aid is requested:
School website:
Date classes start:
Field or Program of Study:
Expected Graduation Date:
CHECK APPROPRIATE CHOICE
For 2014/2015, I will be a:
Freshman
Sophomore

Junior

Senior
I will be enrolled:
fulltime
halftime or more (6+ credits)
I will live:
on campus
Degree with which you will graduate:
at home
less than halftime
Associates Degree
Doctoral Degree
Bachelor’s Degree
Certificate
Master’s Degree
Professional License
Non-degree Program
ACTIVITIES
List all community activities in which you have participated. Include volunteer projects, PTA, etc. Attach
additional sheets if necessary.
Activity
How long?
Special Honors/Offices Held
WORK EXPERIENCE (or enclose a current resume):
Employer
How Long?
Position Held
CAREER GOALS
Please write a short statement about your career goals (attach a sheet if necessary):
SPECIAL CIRCUMSTANCES
Do you have any unusual personal, financial or family circumstances that warrant special attention? (attach a
sheet if necessary).
HOW DID YOU LEARN OF THE ALEXANDER EASTMAN FOUNDATION HEALTH CARE PROFESSIONS
SCHOLARSHIP PROGRAM?
COST of EDUCATION
Please obtain your figures directly from the school’s Financial Aid Office.
COST of EDUCATION
AID AWARDED
Tuition & Fees:
$
Pell Grant:
$
Books:
$
SEOG Grant:
$
Transportation:
$
Stafford Loan: $
Child Care:
$
Perkins Loan: $
Other Expenses:
$
Work Study:
Other Aid*:
Total Cost:
$
Total Aid:
$
$
$
Total Unmet Need (Total Cost minus Total Aid):
$
*Include NH Job Training or Voc Rehab subsidy and employer education reimbursements here
_____________________________________________________________________________________
If you have not applied for financial aid, please explain why:
OUTSTANDING EDUCATIONAL LOANS
Amount Borrowed
Date Loaned
Amount Owed
Unpaid
ATTACHMENTS
With all proposals, please include:
1. Most recent high school or college transcript (if no more than 5 years old).
2. Two letters of professional reference from a supervisor, employer or other person familiar with your work.
3. Cover letter with statement about your reasons for returning to or participating in this course of study.
4. Top two pages of 2013 tax return (please black out the Social Security number).
INCOME, EXPENSES, and ASSET DATA
You must be an independent, adult student to apply for the AEF Scholarship. You are an independent student if you are
24 years of age or older. If you are under 24, you may claim independent status only if you have (1) served in the
military, (2) are a ward of the courts, (3) are married and living away from your parents or (4) have not been claimed by
your parents for two consecutive years and have earned at least $4,000 in each of those two years. Use figures from
your most recent U.S. Income Tax return.
1.
Adjusted annual gross income
$
2.
Total U.S. income tax paid
$
3.
Untaxed income and benefits (Child Support, AFDC, ADC, SSI, etc)
$
4.
Medical/dental expenses not covered by insurance
$
5. Net value of real estate holdings NOT used as primary residence
$
(market value less balance of mortgage)
6.
Total number of family members
#
ADDITIONAL INFORMATION
Your current marital status:
single
married
separated
divorced
widowed
Total number of family members attending college at least half-time during the next academic year (include yourself):
CERTIFICATION
I certify that all the information on this form is true and complete to the best of my (our) knowledge. If asked by an
authorized official of the Alexander Eastman Foundation, I (we) agree to give documentation for information given on
this form. I (we) realize that this proof may include a copy of a U.S. tax return and/or state income tax return. I (we)
realize that failure to comply with a request for further information may prevent the applicant from receiving any aid.
Applicant’s signature: ________________________________________________ Date:__________________________
Spouse’s signature:____________________________________________________Date:_________________________
Print Spouse’s Name:________________________________________________________________________________
Please return completed application and all attachments by June 17. If you have any questions, please contact Betsy McNamara of the Alexander
Eastman Foundation at bmcnamara@alexandereastman.org or 603-219-0699.