2015-16 Education Foundation
Scholarship Application
Jefferson College of Health Sciences Education Foundation is pleased
to offer a variety of scholarships to support the education of
healthcare practitioners throughout the institution thanks to the
generosity of our many donors. Requirements for scholarships vary,
please read the requirements carefully when selecting which
scholarships to apply for. All applications and supporting materials
should be submitted to the Office of Financial Aid.
Checklist for applying for scholarships:
Complete the 2015-16 Free Application for Federal Student Aid (FAFSA) at www.fafsa.ed.gov.
Complete the scholarship application.
Use the chart in the application packet to ensure that you have completed all material (including essays
and recommendations) to be considered for the scholarship for which you are interested.
If applicable, work with appropriate individuals and gather the required number of recommendation
forms. You may need to complete multiple copies to comply with the number of recommendations required.
Forward all materials to the Office of Financial Aid by the May 1, 2015 deadline.
SCHOLARSHIP APPLICATIONS MUST BE SUBMITTED TO THE FINANCIAL AID
OFFICE (OFFICE HOURS M-F 8:30 AM – 4:30 PM) ON OR BEFORE MAY 1, 2015.
APPLICATION PACKETS MUST BE COMPLETE AND INCLUDE ALL REQUIRED
DOCUMENTS. IF ITEMS ARE MISSING THE APPLICATION WILL BE CONSIDERED
INCOMPLETE AND WILL NOT BE REVIEWED.
ALL APPLICANTS WILL BE NOTIFIED BEGINNING JUNE 5, 2015.
Please forward completed scholarship application packet to:
Jefferson College of Health Sciences
Office of Financial Aid
101 Elm Avenue SE
Roanoke VA 24013
Page 1 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
The following materials must be submitted to be considered for each scholarship. You may apply for a maximum of three
scholarships using this one application. Please review the scholarship descriptions carefully to determine which scholarships to
apply for. Essays and recommendations may be used for multiple scholarships. Students may only receive one scholarship per
academic year from the Education Foundation.
REQUIRED MATERIALS
SCHOLARSHIP
Application
Essay 1
Essay 2
Essay 3
Essay 4
Recommendations
required
Essay 5
(2) Surgeon,
Preoperative RN, or
Program Director
Rita M. Bishop Scholarship
X
X
Friendship Retirement Community
Scholarship
X
Two
Dorothy Gibboney Memorial
Scholarship
X
Two
Stanley Kamm Memorial Scholarship
X
Robert Keeley Scholarship
X
Two
Donna Matthews Scholarship
X
Two
Debra Kimmel McNamara
Scholarship
X
James H. Neuhoff Memorial
Scholarship
X
Seavor Scholars Award
X
George Solonevich Scholarship
X
James Sublett Scholarship
X
X
Theresa A. Thomas Memorial
Foundation
X
X
Hugh Trout Scholarship
X
Frederick Louis Troxel
X
X
(2) Employer &
Nursing Faculty
X
X
Two
Two
(3) Instructor,
Counselor, or Business
Professional
X
Two
(2) Employer &
Nursing Faculty
X
X
(2) Attesting to
potential to serve in
an underserved area
Two
X
X
Please forward completed scholarship application packet to:
Jefferson College of Health Sciences
Office of Financial Aid
101 Elm Avenue SE
Roanoke VA 24013
Page 2 of 9
(2) Employer &
Nursing Faculty
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Name:
PowerCampus ID:
SECTION I: Please answer the following questions by choosing the appropriate response. Responses to these questions are not
required, and will not affect the completion status of your scholarship application. However, failure to answer questions may affect
your eligibility for certain scholarships.
Yes
No
Are you currently battling breast cancer, a survivor of cancer or have a family member affected by breast
cancer?
Are you currently employed at Carilion Clinic?
If yes, are you employed at Carilion Clinic as a Registered Nurse?
Are you planning to or interested in working in a geriatric or long-term care setting after graduation?
Are you (or have you been) enrolled in the Adopt-A-Nurse program?
How many community service hours have you completed?
SECTION II: Select up to three (3) scholarships for which you wish to apply. You may apply for up to three (3) using this single
application for the 2015-16 academic year.
1.
2.
3.
SECTION III: Using the space provided on the following pages, please provide written responses to the essay questions indicated.
Responses should be no more than one page in length, double spaced. Required responses to the essay portion of this application
vary by scholarship (see the last page of the scholarship packet). You may choose to answer all of the essay questions, or only those
associated with scholarships in which you are interested. Questions and associated scholarships are listed below as well as on each
subsequent essay page.
Essay question #1: Stanley Kamm, Frederick Troxel, James Sublett, Seavor Scholar, and Theresa Thomas applicants only
Essay Question #2: Stanley Kamm, Frederick Troxel, and James Sublett applicants only
Essay Question #3: Rita M. Bishop applicants only
Essay Question #4: Debra Kimmel McNamara applicants only
Essay Question #5: Theresa Thomas applicants only
Essay Question #6: Theresa Thomas applicants only
Essay Question #7: Theresa Thomas applicants only
Applicant Statement: I certify that all information provided is true and that it may be distributed for the purpose of determining eligibility and awarding of financial
aid. I understand that submission of this application does not guarantee that I will receive or continue to receive scholarship funds. I have read and understand the
financial aid policies for satisfactory academic progress. I understand that Jefferson College of Health Sciences is not responsible for any confidential information
contained in these forms that is intercepted and disseminated by a third party without my knowledge.
Name:
Date:
Page 3 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Essay question #1: Please describe your current commitment to community service, including the number of
hours per week. (Stanley Kamm, Frederick Troxel, James Sublett, Seavor Scholar, and Theresa Thomas
applicants only):
Page 4 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Essay Question #2: Please describe your commitment to a nursing career. (Stanley Kamm, Frederick Troxel,
and James Sublett applicants only):
Page 5 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Essay Question #3: Please describe your commitment to operating room services. (Rita M. Bishop applicants
only):
Page 6 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Essay Question #4: Please describe how breast cancer has had an impact on you or your life. (Debra Kimmel
McNamara applicants only):
Page 7 of 9
Jefferson College of Health Sciences Education Foundation
2015-16 Scholarship Application
For assistance with this application, contact the JCHS Office of Financial Aid
at 1-888-985-8483 or 540-985-8267.
Essay Questions #5: Theresa A. Thomas Applicants only
Please describe your interest and commitment to primary care practice in an underserved area, preferably
rural.
Please briefly explain how you meet either one or both of the following

Origin in Virginia’s medically underserved areas (place of birth, place of residence, schooling, etc.)

Significant interest in serving in Virginia’s medically underserved areas
Please briefly describe your involvement in local, state, regional and national professional activities:
Page 8 of 9
Jefferson College of Health Sciences
Education Foundation
2015-16 Scholarship Application
Recommendation Form
Name of Applicant:
Name of Reference:
Title:
Street Address:
City/State/Zip:
Phone:
E-mail:
Relation to the applicant (for the
purpose of this recommendation):
Current Employer
Former Employer
Business Contact
Colleague
Nursing Faculty
Perioperative RN
Program Director
Surgeon
Faculty/Instructor
Counselor
On a scale of 1 to 4 (1 being the low and 4 being high) please rank this applicant on each item category:
1
2
3
Potential as a healthcare provider
Educational Motivation
Leadership Qualities
4
Oral Communication Skills
Written Communication Skills
Potential for success
Overall recommendation:
Strongly Recommend
Recommend
Do Not Recommend
Please comment on any aspect of the applicant’s background, experiences, community involvement, etc., that will help the
scholarship committee evaluate this individual:
By providing my name below I indicate that all information contained in this recommendation is correct to the best of my knowledge, and it may be distributed for
the purpose of evaluating and awarding scholarships at Jefferson College of Health Sciences.
Name:
Date:
PLEASE COMPLETE THIS RECOMMENDATION REQUEST AND RETURN IT TO THE APPLICANT FOR SUBMISSION WITH THEIR
APPLICATION. THANK YOU FOR YOUR ASSISTANCE.
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