Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Certified Nursing Assistant (CNA) Scholarships are available through the City Colleges of
Chicago (CCC) Foundation for students interested in working with patients who are unable to
care for themselves and as the first step for students interested in pursuing a degree in nursing.
Successful scholars will receive funds to offset fees related to the CNA program including:
tuition costs, textbooks, equipment/uniforms and fees related to the state mandated exam. CNA
scholars will have their fees paid by the scholarship fund upon the successful completion of the
program.
Eligibility Requirements
The applicant must have completed the enrollment process for the CNA Program at one of the
City Colleges of Chicago and have been accepted as a participant in the program.
Applicants must meet with the CNA Coordinator at one of the City Colleges of Chicago offering
the CNA program and work with him/her to complete and submit the full scholarship application
packet including:
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Application Form – completed and signed;
Transcripts (if required);
Applied for WIA funds if they qualify;
Two Letters of Recommendation – one professional/volunteer and one academic;
Signed Application Package Checklist.
CNA Scholarship Funds cannot be used to repeat the CNA program if the student was
unsuccessful previously, and students who do not remain in good standing (70% proficiency on
written tests) may be removed from the program and not receive the scholarship.
Deadlines: The CNA program has a rolling schedule and isn’t tied to the semester system – it’s
not a credit program.
Further details can be obtained from Michael Daigler at mdaigler@ccc.edu.
Revised 5/2011
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Certified Nursing Assistant (CNA) Program Scholarship
City Colleges of Chicago (CCC)
Application Checklist
Directions: Please place a check next to each of the following items when they have been
completed. In order to be considered for the CNA Scholarship, it is required that you complete
all of these items and sign this checklist. Please include the signed checklist as the first page of
your application packet.
Checklist for Scholarship Application Process
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Read about the scholarship eligibility requirements in the Application Packet
Introduction
Ensure that required recommendations (two) have been contacted for references:
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Recommendation from professional or volunteer reference mailed/delivered
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Recommendation from academic reference mailed/delivered
Transcript has been sent (required for high school student or new college transfer
student. A transcript is not necessary if you are transferring from/attending another
CCC location)
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WIA eligibility confirmed/denied
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The CCC CNA Scholarship Application Form completed
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Delivered application materials to Michael Daigler, Vice Chancellor, Development at
CCC (226 West Jackson Blvd, Room 922).
By signing this application checklist, I authorize the CCC Development to access my student
academic records to verify my qualifications as a scholarship candidate (new or renewal) for the
CNA Scholarship.
____________________________________________
Student Signature
__________________________________________
Printed Name
Revised 5/2011
________________________
Date
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Thank you for your interest in a CCC CNA Scholarship Program. Please use the enclosed CNA
Scholarship Application Checklist to ensure your application is complete. Also, carefully review the
eligibility requirements on the cover page of the application packet.
It is your responsibility to ensure that a complete application packet and letters of
recommendation are mailed or delivered to the address below prior to the application
deadline. Deadlines are determined by Michael Daigler – mdaigler@ccc.edu.
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Recommenders can send their completed recommendations directly to the address below
or they can be delivered in a sealed envelope with all other application materials.
Recommendation Letters should be clearly marked with the applicants name,
recommenders name and whether their reference is academic or professional. If the letters
are to be mailed, provide an addressed, stamped envelope to each recommender to
facilitate this process.
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Applications lacking any required information will be considered incomplete and will not
be considered.
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APPLICATION REQUIREMENTS
Application Form
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Reviewed eligibility criteria and other information provided in the application packet.
Completed and signed application, including responses to all questions.
Ensure two completed recommendation forms, from two different references, were sent directly to the
address below, or can be included in your submitted application. One recommendation must cover your
academic capabilities and one must cover your professional capabilities.
Transcripts
High School Applicants
(Required if 6 credit hours or less of
college has been completed)
Transferring College Applicants
(Required if transferring from a nonCCC college)
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Enclosed transcript
Enclosed ACT or SAT test
scores
Return completed application
and for questions to:
Revised 5/2011
Enclosed transcript
City Colleges Applicants
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Transcript not required
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Michael Daigler, Vice Chancellor
Development
City Colleges of Chicago
226 West Jackson Blvd, Room 922
Chicago, IL 60606
Mdaigler@ccc.edu
Revised 5/2011
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Name of scholarship: CNA Scholarship
Have you ever received this scholarship?
Date:
□ Yes, term_______________________
□ No
Name:
Last
First
MI
U.S. Citizen? Yes ___ No ___
Student ID:
Permanent US Resident? Yes ___ No ___
Ethnicity (optional, circle all that apply):
African American
Asian American
Caucasian/white
Native American
Other: ________________________
Date of birth: ____/____/________
Gender: M F
Permanent address:
Street address
Apartment number
City
Phone(s):
Hispanic American
State
______-______-________
Postal code
Email:
______-______-________
High School (ONLY IF fewer than 6 credit hours of college have been completed)
________ based on a ________ scale
Cumulative GPA:
Transcript attached:
Yes ___ No ___ (to be sent separately) ACT ___ SAT ___
College (ONLY IF transferring from a non-CCC college*)
*Note: no need to submit a transcript
for City Colleges coursework.
Cumulative GPA:
________ based on a ________ scale
Transcript attached:
Yes ___ No ___ (to be sent separately)
Colleges/universities attended (other than City Colleges of Chicago)
Institution
Dates of Attendance
Credits/Degree/Certificate Earned
--Which City College you are attending/would you like to attend?
Course of study: CNA
What is your long-term education goal?
Expected completion date:
What is your long-term career goal?
Rev. 5/11– CCC/MD/LMV
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Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
Application Form
Directions: Please answer the following questions to assist the scholarship committee in
understanding what makes you an outstanding candidate for the CNA Scholarship. Attach a
separate piece of paper if needed.
Work Experience: Please tell us about your work experience (paid/voluntary/part-time/full-time).
Tell us about the kind of work you do, and how many hours you work each week.
Organizational Involvement: If you work for or with a community organization, please tell us how
long you have been involved with the organization, and the mission and goals of the organization.
Mandatory Question: Why are you applying for this scholarship and how would this award be
helpful to you? This is a very important question so give your answer careful consideration. (Feel free
to attach separate sheet of paper, if needed.)
Optional: Please include any other information which could be helpful in evaluating this application
(attach separate sheet, if needed).
How did you hear about this scholarship?
I hereby certify that the information provided in this application is, to the best of my knowledge, true and correct. I have not knowingly withheld
any facts that could otherwise jeopardize consideration of my application. Pursuant to the Family Educational Rights and Privacy Act of 1974, as
amended (FERPA), I hereby authorize the City Colleges of Chicago to release the scholarship application information provided by me, as well as
other official City Colleges of Chicago information regarding my academic progress and status, for the purpose of evaluating my eligibility as a
scholarship recipient. I understand that if any information provided on this application is found to be inaccurate, my scholarship may be revoked.
I understand that scholarship awards are based on the availability of funds.
Signature of applicant
Date
Printed name of applicant
Rev. 5/11– CCC/MD/LMV
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Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
RECOMMENDATION FORM
Applicant: Complete the top portion of this page and give it to a recommender who knows your work well; for
example: employment or volunteer references and an academic reference who knows your work as a scholar. As a
courtesy to your recommender, please provide him or her with a stamped envelope addressed as indicated below.
Name:
Student ID:
Deadline:
Name of the person completing this recommendation form:
Please explain your relationship to this person:
OPTIONAL WAIVER OF RIGHT OF ACCESS
The Family Educational and Privacy Act of 1974, as amended, allows a candidate for admission, employment or receipt of honors to waive his or
her right of access to confidential letters or statements written in his or her behalf if the recommendation is used solely for the purpose of admission,
employment, or the receipt of honors and if the candidate, upon request, is notified of the name of all persons making such recommendations on his
or her behalf. The City Colleges of Chicago does not require that you make such a waiver as a condition for admission or award of a scholarship.
However, you have the option of signing such a waiver as below in the event that your recommender requires that you waive access to the
recommendation.
I hereby waive my right of access to this recommendation form and any appropriate attachments which have been written by the above named
person on behalf of my City Colleges scholarship application.
Applicant’s signature:
Date:
Recommender: Thank you for agreeing to submit a recommendation in support of this scholarship applicant. Your
comments will not be disclosed to the applicant (if the above optional waiver has been signed), will be available only to
those involved in the scholarship decision process, and will be destroyed when no longer needed for scholarship
decision purposes. Please use this form to provide an evaluation of this applicant (use additional pages, if needed).
Complete both pages of the form and sign it. Thank you very much for taking the time to provide this critical input!
Name:
Phone:
Position:
______-______-________
Email:
How long and in what capacity have you known the applicant?
What three or four words would you use to describe the applicant?
Please rate the applicant in each of the following areas:
Potential for college success
Personal initiative
Motivation
Intellectual curiosity
Social ability
Creativity (scholastic or artistic)
Leadership
Maturity and integrity
Commitment and follow through
Rev. 5/11– CCC/MD/LMV
One of the
Best I’ve
Ever Seen
Excellent
Above
Average
Average
Below
Average
Not Able to
Rate
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1
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
RECOMMENDATION FORM
Applicant’s name:
What are the applicant’s principal strengths?
What are his/her principal areas for development?
How has the applicant demonstrated leadership ability and commitment to the community?
If possible, please give specific
example.
Overall, I rate this scholarship applicant as follows:
Enthusiastically
Strongly
Fairly
strongly
Without
enthusiasm
Not
recommended
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For professional ability
For character and personal distinction
If you have additional comments that would assist the Scholarship Review Committee in
making a decision, please use the space below or attach an additional sheet of paper.
Thank you again for your help!
Signature of recommender
Date
Printed name of recommender
Please return this form and any additional sheets to: Michael Daigler, Vice Chancellor, Development, 226 West
Jackson Blvd, Room 922, Chicago, IL 60606
Rev. 5/11– CCC/MD/LMV
2
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
RECOMMENDATION FORM
Rev. 5/11– CCC/MD/LMV
3
Certified Nursing Assistant (CAN) Program Scholarship
City Colleges of Chicago (CCC)
RECOMMENDATION FORM
Rev. 5/11– CCC/MD/LMV
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