Chi Eta Phi Sorority, Inc., Gamma Chi Chapter

A Professional Nursing Organization

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                                                                  APPLICATION FOR

                                              BELLAMY, ROWSER, BINNS, CHI FELLOWS AWARD

                                                                                             

                                                      Minority Student Nurse Scholarship Application

 

                                                                     MOTTO:  SERVICE FOR HUMANITY

        

     Eligibility Criteria:  (Check One)

 

        ___African American  ___American Indian ___ African (Naturalized) ___Hispanic  ___Asian/Pacific Islander

 

 

1.    APPLICANT

 

A.       Name ………………………………………………………………………………… SS# ……………………………                                                                          

                    (First)                                              (Last)                                             (MI)

 

B.      Address …………………………………………………………………………………………………………………

 

City …………………………………………    State ……………………… Zip …………………………………….

 

Home Phone……………………………. Work…………………………. Cell ………………………………………

 

1.       Do you live on campus?  Yes.  No …… If yes, Name of Dorm.

 

………………………………………………………………………………………………………………………

                   

2.       If  no, with whom do you live?  …………………………………………………………………………………..

 

………………………………………………………………………………………………………………………

 

C.      Date of Birth …………………………………  Place of Birth ……………………………………………………….

 

D.      Check one: ……Single …….Married …….Divorced ……..Widowed …………..Separated

 

E.       Are you a citizen of the United States? …….Yes …….No

F.       If no, are you a permanent resident of the United States? ……. Yes …….No

 

Please describe circumstances ……………………………………………………………………………………………..

 

………………………………………………………………………………………………………………………………..

 

………………………………………………………………………………………………………………………………..

 

Church Affiliation  ………………………………………………………………………………………………………….

 

II.  CHARACTER REFERENCES  (Give names and addresses of two persons, not your relatives.  Give them the enclosed

                                                               Reference Form with instructions to submit as noted on the form.)

 

 

           A  .…………………………………………………………………………………………………………………………….

                      (Name)                                                           (Address)                                                                             (Relationship)

 

             B .……………………………………………………………………………………………………………………………………………………………..                        

                          (Name)                                                            (Address)                                                                             (Relationship)

 

Photocopies of this application are acceptable.   Type or use Black ink only.  Pencil is not acceptable.

 
 

 

 

 


III:    FAMILY INFORMATION

      

           A.   Father  ....………………………………………………………………………………………………………………….      

                                Name                                                                   Address                                                                                 Occupation

 

      

          B.   Mother ……………………………………………………………………………………………………………………

                               Name                                                       Address                                                                                 Occupation

       

         C.   Spouse  …………………………………………………………………………………………………………………….

              Name                                                                     Address                                                                           Occupation

               

D.       Number of siblings dependent on parents:  (   )     Number of children dependent on you/spouse:  (   )

 

 

IV.   EDUCATION

 

        A.    High School  ……………………………………………………………………………………………………………..

 

                 Address  …………………………………………………………………………………………………………………

 

                 High School Scholastic Average   ……………

 

                 Name and address of the college in which you are enrolled and or attended: ……………………………………..         

                

                …………………………………………………………………………………………………………………………….

 

        B.     Name of                                                      Address                            Year (s) of                                 Degree/

  College/University                                                                              Attendance                               Diploma

 

……………………………………………………………………………………………………………………………………………………………

 

……………………………………………………………………………………………………………………………………………………………

 

……………………………………………………………………………………………………………………………..

 

 

C.     Current Educational Status:

 

1. ………………………………………………….............................................................................................................

       Classification: (Freshman, Sophomore, Junior, Senior.)

 

                   2. In what area of nursing are you most interested? ………………………………………………………………….

 

                    ………………………………………………………………………………………………………………………….

 

 

V.     EMPLOYMENT STATUS

 

A.    Are you presently employed? ……Yes. ……No.  If yes: Full Time ……  Part Time…

 

B.    Where?  (List Address)  ………………………………………………………………………………………………….

 

…………………………………………………………………………………Work Phone:…………………………..

        

C.    Type of Work/Job Title.  …………………………………………………………………………………………………

 

D.    If you are a licensed nurse, in what state (s) are you currently registered?  State……………..Reg.  # …………….

 

State……………………………….. Reg.  #……………………  State…………………………. Reg. #………………

 

 

 

 

 

 

VI.    EXTRA-CURRICULAR ACTIVITIES

         

          A:  List the Clubs and /or Organizations in which you take an active part.  ……………………………………………

                 

                  ……………………………………………………………………………………………………………………………

 

B.      List Honorary Societies in which you belong.  ……………………………………………………………………….

 

 

C.   List office(s) held in any Clubs and or Organizations.  ………………………………………………………………

 

…………………………………………………………………………………………………………………………….

 

  D.  List all awards, Honors or Citations received.  ………………………………………………………………………

     

                  ……………………………………………………………………………………………………………………………

 

    E.  List any Sorority to which you belong.   ………………………………………………………………………………

 

…………………………………………………………………………………………………………………………….

 

…………………………………………………………………………………………………………………………….

   

 

VII.    FINANCIAL STATUS

 

         A.  Are you currently receiving financial assistance? ……. Yes   No ……

 

B.    If yes, please complete.

 

Name of Grant/Loan                                                                             Name of Scholarship

 

1. ………………………………………………………………           1. …………………………………………………….

 

2. ………………………………………………………………           2. …………………………………………………….

 

3. ……………………………………………………………….          3.…………………………………………………….

 

C.    If you are awarded a scholarship from Gamma Chi, for what purpose will you use it? …………………………….

 

…………………………………………………………………………………………………………………………….

 

…………………………………………………………………………………………………………………………….

 

 D.  Attachι any pertinent information that would be helpful in assessing your financial need for this scholarship.

 

  

       ______________________________________________________           ___________________________________

                          Signature of applicant                                                                                         Month/ Date/ Year

                    

APPLICANT MUST ENSURE THE FOLLOWING:

 

·         Submit the most recent transcript directly from the registrar’s office to the Committee at the stated address.

·         Provide financial data from respective College/University or School of Nursing.

·          Reference information must be mailed directly from provider to the Committee at the stated address.

·          Photograph of Applicant (most recent).

·         Letter from the applicant (Biography or “Why I want To Be A Nurse”).

·         All information and Application reaches the Committee by Deadline of March 18, 2008.

·         Address:  Chi Eta Phi Sorority, Incorporated, Gamma Chi Chapter GNA Headquarters

       3032 Briarcliff Road, Atlanta, Ga.  30329-2655