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2013 Scholarship Form
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College of Nursing Information
2013 Scholarship Form
First Name
*
Middle Initial
Last Name
*
Gender
No Comment
Female
Male
Race
No Comment
African American
Asian / Pacific Islander
Hispanic
(Native) American Indian
(Caucasian) White
Other
Email Address (USC Preferred)
*
Phone Number
*
Permanent Street Address
*
City
*
County
State
*
Postal Code
*
Estimated personal income per year ($)
Estimated spouse income per year ($)
Estimated parent(s) income per year ($)
Estimated other income per year
Optional - Explain other income
Are you currently receiving any other financial aid?
Yes
No
Do you anticipate receiving any other financial aid?
Yes
No
List any grants/loans/scholarships you anticipate receiving
List the total amount of aid you anticipate receiving in 2013
What degree program will you be enrolled in Fall 2013?
Bachelor of Science in Nursing (BSN)
Master of Science in Nursing (MSN)
Post-Master Certificate of Graduate Study in Advanced Practice Nursing
Master of Science in Nursing/Master of Public Health
Doctor of Nursing Practice (DNP)
Doctor of Philosophy in Nursing Science (PhD)
Type of Student
New
Continuing
Transfer
Level of Student (BSN only)
N/A
Incoming Freshman
Lower Division (continuing Freshman or Sophomore)
Applied for Upper Division
Senior
Degree Emphasis (MSN only)
N/A
Acute Care Nurse Practitioner
Adult Nurse Practitioner
Community/Public Health Clinical Nurse Specialist
Family Nurse Practitioner
Pediatric Nurse Practitioner
Psychiatric Mental Health Clinical Specialist
Psychiatric Mental Health Practitioner/Specialist
Women's Health Nurse Practitioner
Level of Preparation (DNP/PhD only)
N/A
Non-BSN prepared
BSN prepared
MSN prepared
Projected Graduation Semester
Spring
Summer
Fall
Projected Graduation Year
2013
2014
2015
2016
2017
2018
2019
2020
Why you deserve to receive a scholarship? (100 words or less)
List an example of your innovation. (100 words max)
Are you currently an RN working in critical care?
N/A
YES
NO
Are you a single parent?
N/A
Yes
No
Applicant is a resident of
N/A
Union County, SC
Kershaw County, SC
Springfield County, SC
Applicant intends to work with
N/A
Substance abuse research (no experience)
Substance abuse research (with experience)
Alcohol abuse research (no experience)
Alcohol abuse research (with experience)
AIDS/HIV research (no experience)
AIDS/HIV research (with experience)
Oncology research (no experience)
Oncology research (with experience)
Applicant was
N/A
born and raised in Richland County, SC
born and raised in Lexington County, SC
a resident of Carolina Children's Home
a resident of Epworth Children's Home
Applicant is a member of
Any chapter of Sigma Tau International Honor Society
Alpha Xi Chapter of Sigma Theta Tau International Honor Society
AACN
Student Nurses Association (SNA)
South Carolina Nurses Association - Any Chapter
South Carolina Nurses Association - Central Midlands Chapter
The college can use my name/award amount in marketing materials
Yes
No
My contact information can be released to my scholarship donors
Yes
No
I will write a letter of appreciation to my award donor(s)
Yes
No
I am willing to attend a function with award donors
Yes
No
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