Applicant Information
Last Name :
Middle Initial :
First Name :
Street Address:
Apartment/Unit # :
City :
State :
Zip :
Phone :
( )- -
E-mail :
   
Education
High School :
Address :
From:
 (mm/yy)
To:
 (mm/yy)
Did you graduate?
Degree:

College :
Address :
From:
 (mm/yy)
To:
 (mm/yy)
Did you graduate?
Degree:

Other :
Address :
From:
 (mm/yy)
To:
 (mm/yy)
Did you graduate?
Degree:
   
Employment

I am currently employed as a (an) .

I am enrolled in a nursing school to upgrade my career to:

Current Employer :
Address :
Job Title :
From:
 (mm/yy)
To:
 (mm/yy)
Years of experience in long term care :
Phone :
( )- -   x:
Supervisor:
 
Nursing School
Name :
Street Address:
City :
Phone :
( )- -
Expected Start Date :
 (mm/yy)    
   
Other
a. Describe your interest in long term care, including how you became interested in the profession and related experiences you have had:
 
b. The terms “quality of care” and quality of life” are used frequently in reference to long term care. What does this mean to you and what do you do to assure that your residents are receiving quality care and maximizing their quality of life?
   
c. Describe your future professional plans in the health care field and your commitment to long term healthcare:
   
d. Briefly describe how you plan to fund your education:
   

TERMS OF AGREEMENT

The John W. Maitland, Jr.-Joseph F. Warner Long Term Care Nurses Scholarship Fund will award up to a $1,000 provisional scholarship for the 2013 Fall Semester directly to the applicant’s nursing school for the benefit of the applicant. If the award recipient fails to satisfactory complete coursework in during the semester for which the scholarship is rewarded, the scholarship award must be returned to the Scholarship Fund. Deadline for submission of all materials is June 3, 2013.

ELIGIBILITY REQUIREMENTS

  • Must have completed the prerequisites for an RN or LPN program and be accepted into a nursing program on a full-time basis.
  • Must be working in an assisted living or long term care facility (either full-time or part-time).
  • Must provide proof of satisfactory completion of the semester for which the scholarship is awarded.
  • Should be willing to work as an RN or LPN in an IHCA-member facility/program.

REQUIRED INFORMATION OR DOCUMENTATION

The following supporting information/documentation is required to be submitted, in hard copy format, to Ms. Gina Alex at:

Illinois Health Care Association
Attn: Gina Alex
1029 S. Fourth Street
Springfield, IL 62703

  • A copy of the letter of acceptance from the nursing school.
  • Proof of completion of prerequisites for the RN or LPN program (as applicable).
  • Two (2) letters of recommendation, one by the facility/program Administrator and one by the Director of Nursing.
  • An evaluation form completed by the Administrator or Director of Nursing.
  • Deadline for submission of all materials is June 3, 2013.

DECISION

Final determination of scholarship awards will be made by the John W. Maitland, Jr.-Joseph F. Warner Long Term Care Nurses Scholarship Fund Board of Directors by July 31, 2013.

ACKNOWLEDGMENTS

I understand and agree with the terms of the Agreement and Eligibility Requirements, and wish to be considered for a John W. Maitland, Jr.-Joseph F. Warner Long Term Care Nurses Scholarship Fund scholarship.

I have printed an evaluation form and understand that the evaluation form must be completed by the Administrator or Director of Nursing.

Print a copy for my records