Fillable Black Hawk College East Foundation Dual Enrollment CNA (Black Hawk College)

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Black Hawk College East Foundation Dual Enrollment CNA (Black Hawk College)

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The Black Hawk College East Foundation Dual Enrollment CNA (Black Hawk College) form is 2 pages long and contains:

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  • 14 check-boxes
  • 53 other fields

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File type: PDF

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Black Hawk College East Foundation
Dual Enrollment CNA Scholarship Application
Date of Application: ____________________________
Application Instructions
To be considered applicant must:
1. Complete Black Hawk College Dual Credit Admissions Application if you are a new student.
2. Complete CNA Scholarship Application, including personal statement.
Transcripts required:
• Current high school students must submit a current high school transcript.
Return completed application to: Black Hawk College East Foundation
26230 Black Hawk road
Galva, IL 61434
(or email to: breedlovel@bhc.edu)
Please Print or Type
l. Personal Data:
Name: __________________________________________________________________________________________
Last First Middle
Student ID Number: _________________________________________ Phone: _______________________________
Address: ________________________________________________________________________________________
Street City State Zip Code
County: _________________________________________ Email: _________________________________________
High School Attended: ____________________________________________________________________________
Date of Birth (must be 16 years or older): _______________________________________________________________
Home Schooled: o Yes o No
Household Income: o $0 - $5,000 o $5,000 - $10,000 o $10,000 - $25,000 o $25,000 - $50,000
o over $50,000
ll. Black Hawk College Enrollment:
Check one: o New College Student o Returning BHC Student o Transferring to BHC
o High School/Dual Enrollment Student
3 when
completed
o
o
o
lll. Community Involvement and Honors:
List high school, college or community organizations and/or activities in which you have been involved or have
received honor. (Examples: sports, clubs, volunteer work.)
Organization or Activity Nature of Participation Date(s) of Participation
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
Honors, Awards or Accomplishments Date Received
_________________________________________________________________________ ____________________
_________________________________________________________________________ ____________________
_________________________________________________________________________ ____________________
_________________________________________________________________________ ____________________
_________________________________________________________________________ ____________________
lV. Work Experience: (Attach additional page if needed.)
List recent part-time and full-time jobs
Employer Hours/Week Dates
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
________________________________________ ______________________________ ____________________
V. Submit a 1-2 page typed personal statement and attach to your application. This is your opportunity
to address the Scholarship Committee. Your statement must be a minimum of 150 words.
The following are ideas you may want to include in your statement:
• Why are you interested in the Black Hawk College Certified Nursing Assistant Program?
• What are your plans for the future? Will you continue your education after Black Hawk College?
• Why should you receive a CNA scholarship?
Vl. Certification
I certify the statements herein are true to the best of my knowledge and grant my permission for the information
contained herein to be shared with the Scholarship Committee.
I understand information from my academic history may be released to the Scholarship Committee.
If awarded a Scholarship, I release to Black Hawk College the right to use my name and picture for publications,
reports and press releases.
If I receive a scholarship, I will send a thank you note to the Foundation Office to be passed on to the benefactor.
I realize that if I receive a scholarship, I am expected to attend the Fall Scholarship Banquet.
Applicant’s Signature: __________________________________________________ Date: ______________________
Parent/Guardian’s Signature : ____________________________________________ Date: ______________________
Black Hawk College will make all educational and personnel decisions without regard to race, color, religion, gender, sexual orientation, marital status, national origin or ancestry, age, physical or mental
disability unrelated to ability, or status as a disabled veteran or Vietnam era veteran, except as specifically exempted by law. If you need an accommodation based on disability to fully participate in this
program/event, please contact Disability Services at 309-796-5900, 309-796-5903 (CAPTEL) or 309-716-3310 (video phone).
18810KM02/19
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Black Hawk College East Foundation Dual Enrollment CNA (Black Hawk College)

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Completed 25 July 2020

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