School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
St. Mary's Medical Center Auxiliary
Offers LSC Student Scholarships for
Health Division Fields
Criteria:
Scholarships of $1,500 each will be awarded and one payment made to Lake Superior College August, 2016

The Scholarships will be awarded to students pursuing careers in the Health Science Professions at Lake Superior
College.

Students must have been accepted into and taking classes within their major program profession in order to apply
for a scholarship. The eligible program majors at Lake Superior College are: Medical Laboratory Technician,
Nursing AAS, Physical Therapist Assistant, Nursing Advanced Standing Track, Practical Nursing, Radiologic
Technology, Respiratory Therapy and Surgical Technology.

Applications are reviewed with an emphasis on past/current volunteer activities. Consideration is also given to
demonstrated financial need, academic record and the commitment to caring for the sick and injured.

Applications are due February 2, 2016 and selection will be made in March 2016.

Recipients will officially be notified in March and recognized in April 2016.
When requesting the reference, it is suggested that you provide the individuals with the reference form, along with a
stamped addressed envelope.
PLEASE NO HAND-WRITTEN APPLICATIONS WILL BE ACCEPTED
This application will be made available to download via the
Lake Superior College web site.
LSC
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School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
LSC 2016 Scholarship
Since personal interviews are not used to determine recipients, it is to the candidate's advantage to provide essential information that will
aid the Scholarship Committee in making the final selections.
No handwritten applications are accepted
Date:
Name
(Last)
(First)
(Middle)
Mailing Address
Street
Telephone: (
City
)
State
Zip
State
Zip
E-mail
Home Address if different than above
Street
City
Birth Date (month, date, and year)
Age
Social Security #____________________________ Student ID
Have you applied previously?
Single
Married
No
Yes
If so when
Spouse’s Name:
Spouse’s occupation:
Give names, ages of children living at home and supported by you:
Name
Age
School Year
Please check the department in which you are pursuing your degree:
Medical Laboratory Technician
Practical Nursing
Nursing AAS/AS
Radiologic Technology
Physical Therapist Assistant
Respiratory Therapy
Nursing Advanced Standing Track
Surgical Technology
Date of acceptance into Major Program:
LSC
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School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
Financial Information:
A.
Expenses:
Tuition/yearly
Board & Room/yearly
$
B.
C.
Loans:
$
Amount
Type
Date Borrowed
$
$
$
$
$
$
Savings to date: (bank, bonds, investments)
Applicant’s income
Spouse’s income
$
$
Expected total work income for next school year $
Other scholarship aid:
Source
Amount
Date Awarded
$
$
$
Employment Experience:
Start with your present or last job. Include any job related military service assignments.
Employer/Address/Phone
LSC
Dates Employed
From/To
Hourly Rate
Salary
3
Work Performed
School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
The mission of Essentia Health St. Mary's Medical Center is: We are called to make a healthy difference in People’s lives.
Please give a BRIEF statement as to WHY you have selected your particular field of study and how you hope to use this field to
benefit your community in the future.
St. Mary's Auxiliary is a volunteer organization that provides volunteers and raises money for St. Mary's Medical Center. Please
give a CONCISE LIST of your past and current volunteer experiences.
(Date)
LSC
(For Whom/Where)
(Type of Organization)
4
(Responsibilities)
School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
Please list the names and titles of the persons from whom you have requested recommendation (forms #1, #2, # 3) for this
scholarship application:
_______________________________________________
(Name)
____________________________________________
(Title)
_______________________________________________
(Name)
___________________________________________
(Title)
_______________________________________________
(Name)
____________________________________________
(Title)
FORM 1 Reference:
FORM 2 Reference:
FORM 3 Financial Aid Information:
Submit to Program Director/Instructor – Major Field
Submit to the Professional Reference
Submit to the Director of Financial Aid
DO NOT SUBMIT APPLICATION WITHOUT UNOFFICIAL TRANSCRIPT OF COURSES COMPLETED
All the information listed above constitutes my application for the St. Mary's Scholarship is correct and true to the best of my
knowledge and belief. I am aware that all information shared regarding financial information and references will be shared with the
Scholarship Committee and will remain confidential.
The undersigned does hereby consent to permit:
 Essentia Health
 Newspaper
(Media Outlet or Contractor)




Interview
Photograph
Videotape
Audiotape
The undersigned understands that the interview, photographic images, video recording and/or audio recording may be used for
 Educational purposes
 Publication, including but not limited to newspapers, television, radio broadcasts, books, brochures, magazines, and/or
website publications in such manner and at such time and in such places as determined by Essentia Health and/or the
above-named media outlet or contractor.
Date:
Signed:
Signature of the Applicant
LSC
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School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
FORM#1
Reference - Program Director/Instructor
Name________________________________________________________________________________________________
(Last)
(First)
(Middle)
College Department_________________________________________Current College Year__________________________
To the applicant:
After completing the above, please give this form to a Program Director or Instructor in your major
field for a recommendation.
To the Program Director/Instructor: ALL INFORMATION WILL BE KEPT CONFIDENTIAL.
The above named student has made application for scholarship aid from our organization. We will appreciate your assistance in
giving us the following information so we may help deserving students. This confidential Reference Form must be mailed directly
to the address below. Thank you in advance for returning this form by due date February 2, 2016.
If you feel a rating falls between two categories, so indicate by placement of the check mark. As we do not do personal
interviews, your input is very important to us. If we need further information, may we call you? __________
Please list your phone number _____________________
Excellent
Good
Fair
Poor
Comments
General Professional Potential
Integrity
Intellectual Capability
Quality of Work Performed
Diligence
Cooperation & Attitude
Initiative & Enthusiasm
Dependability
Caring/Sensitivity
SIGNED:_____________________________________________DATE:_______________________________
Program Director/Instructor
LSC
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School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
FORM #2
Reference – Professional Reference
Name
_________________________________________________________________________________________________________
(Last)
(First)
(Middle)
College Department____________________________________________ Current College Year________________________
To the applicant: After completing the above, please give this form to a Professional Reference.
To the Professional Reference:
All INFORMATION WILL BE KEPT CONFIDENTIAL.
The above named student has made application for scholarship aid from our organization. We would appreciate your assistance in
giving us the following information to aid in our selection process. This confidential Reference Form must be mailed to the above
address. Thank you in advance for returning this form by due date February 2, 2016.
If you feel a rating falls between two categories, so indicate by placement of the check mark. As we do not do personal
interviews, your input is very important to us. If we need further information, may we call you? __________
Please list your phone number _____________________
Excellent
Good
Fair
Poor
Comments
General Professional Potential
Integrity
Intellectual Capability
Quality of Work Performed
Diligence
Cooperation & Attitude
Initiative & Enthusiasm
Dependability
Caring/Sensitivity
SIGNED: ________________________________________________________DATE:________________________________
Professional Reference
LSC
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School Year 2016
Deadline Date: February 2, 2016
Mail completed application to:
St. Mary’s Medical Center Auxiliary
Att: Scholarship Committee
407 East Third Street, Duluth MN 55805
218 786-4420
FORM #3
Financial Aid Information
Name_________________________________________________________________________
(Last)
(First)
(Middle)
College Department: _____________________________________________________________
Current College Year: _________________ Student ID
To the applicant: After completing the above, please give this form to the Director of Financial Aid for the following
information.
Attention Director of Financial Aid:
ALL INFORMATION GIVEN IN THIS APPLICATION WILL BE
KEPT CONFIDENTIAL WITH THE COMMITTEE.
The above named student has made application for scholarship aid from our organization. We would appreciate your assistance in
giving us the following information so we may help deserving students. Thank you in advance for returning this form by due
date, February 2, 2016
1.
Which year of eligibility criteria is being used?
Current Year
2.
Next Year
What is the applicant's Federal Financial Aid Eligibility?
Level #______________________________________________
3.
Please comment regarding applicant's need for financial assistance:
________________________________________________________________________________________________
________________________________________________________________________________________________
SIGNED: __________________________________________________DATE:_____________________________________
Director of Financial Aid
LSC
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