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NURSING SCHOLARSHIP APPLICATION - 2021 Scholarship. Scholarships available

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NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 1 of 8
GENERAL INFORMATION:
Hospital for Special Care (HFSC) welcomes students pursuing initial degrees in nursing to apply for a 2021 Nursing
Scholarship. Scholarships available are made possible through established charitable funds. Six scholarships will be
awarded to students enrolling or enrolled in an accredited college/university as full-time or part-time undergraduate
students and meeting the eligibility criteria below.
SCHOLARSHIP AMOUNTS:
The Rona Botwinick Nursing Scholarship - $3,000
The Florence Timura Nursing Scholarship - $3,000
The Dr. Michael Timura, III Nursing Scholarship - $2,750
The Paul Sutula Nursing Scholarship - $2,500
The Elizabeth Timura Gold Star Mother Nursing Scholarship - $2,500
The John Timura Nursing Scholarship - $2,500
ELIGIBILITY REQUIREMENTS:
This scholarship is open to:
Students residing in the Greater New Britain Area in one of the following towns: New Britain, Berlin,
Farmington, Newington, Plainville or Southington
Students enrolling or enrolled in an associate or baccalaureate degree program, pursuing a Registered Nurse
degree (Note: Students pursuing an RN to BSN program or who already are a Registered Nurse do not qualify)
ADDITIONAL ELIGIBILITY REQUIREMENTS:
Must maintain a minimum of a 2.75 grade point average on a 4.0 scale
APPLICATION SUBMISSION INSTRUCTIONS AND DUE DATE:
Applications for the scholarship must be postmarked by May 10, 2021. Applications postmarked after this date will
not be considered. This application becomes complete and valid ONLY when applicants have returned all
documentation indicated on the checklist on page 2.
Please type the information requested. All responses must be completed on this form. Use only the space provided for
your answers. Please DO NOT submit a CV or additional pages.
SUBMIT ALL MATERIALS TO:
Hospital for Special Care Foundation, Inc.
Attn. Laura Gervais
2150 Corbin Avenue, New Britain, CT 06053
NOTIFICATION AND AWARD:
The recipient will be notified in June, and the award will
be sent directly to the school by September.
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 2 of 8
APPLICANT INFORMATION
This is the ONLY area of the application where your identifying information will appear. Please use only the last four digits of your social security
number as an identifier on all subsequent pages and attachments.
Name (First):
(Middle):
(Last):
Street Address:
City:
State:
Zip:
Email:
Preferred Phone:
Alt. Phone:
Date of Birth:
Check all that apply:
I am a student residing in the Greater New Britain Area in one of the following towns: New Britain, Berlin, Farmington,
Newington, Plainville or Southington.
I have NOT received a nursing scholarship from HFSC in the past.
I I am an immediate family member of a Hospital for Special Care benefit–eligible employee.
Family member name:
Relationship (please indicate): Child Spouse Grandchild
CHECKLIST:
Before you return your application package, please verify that you have enclosed the following documentation. Incomplete
applications will be disqualified and will not be reviewed.
Check each box to verify completion:
Completed Application (please complete all sections on pages 2-8)
Please include the following:
A personal statement essay, describing career goals and future aspirations (Limit to 300 words; please use page 8
provided or regular white paper, double-spaced, with one inch margins)
Academic transcript(s) – copy/unofficial transcripts/score is acceptable
Documentation of residency (copy of driver’s license, passport, voter registration)
Documentation of acceptance to nursing program
Documentation of college tuition and fees
Two letters of recommendation: (must be sealed in an envelope and signed across sealed flap)
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 3 of 8
CERTIFICATION:
In submitting this application, I certify that the information provided is complete and accurate to the best of my knowledge. If
requested, I agree to submit proof of information I have provided on this form. Falsification of information may result in termination
of any scholarship granted. This application and attached materials become the property of Hospital for Special Care Foundation,
Inc.
Applicant’s Signature: _______________________________________ Date: _______________________
Parent/Guardian Signature: _______________________________________ Date: _______________________
Required if you are claimed as a dependent on tax forms, even if you are over 18.
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 3 of 8
ACADEMIC PROFILE/HISTORY
Instructions: This section must be completed and signed by an official of your school.
The GPA must be reported as its equivalent on a 4.0 scale and certified by a school official.
Failure to report grade-point average on a 4.0 s
cale may disqualify this application.
If the school does not use GPA, please provide similar information:
Cumulative grade-point average: /4.0 scale
Class rank if applicable: of
School Official Signature: __________________________________ Date: ___________________________
School Official Title: _____________________________________ Telephone: ______________________
School: _____________________________________________________________________________________
Address: _______
_____________________________________________________________________________
Street City State Zip
Important: Enclose academic transcript from your high school, post-secondary programs, or vocational/technical
schools attended.
COLLEGE/ UNIVERSITY CURRENTLY ATTENDING: 2021-2022
School:_________________________________ City: _____________________ State: ________
Status for the September 2021-2022 academic year:
Class you will be entering in September 2021:
Full-time Part-time
Freshman
Sophomore
Junior Senior
Other/Explain: ________________________________________
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 4 of 8
ACADEMIC HISTORY
Beginning with high school, please list all schools you have attended:
School
Major Subject
Graduation
Date (mm/yy)
ACADE
MIC HONORS: List academic honors received in the past four years. Limit to the ten most recent.
NAME:
DATE RECEIVED:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 5 of 8
EMPLOYMENT HISTORY, EXTRACURRICULAR ACTIVITIES, AWARDS, OTHER
Employment (Limit to 5; please start with most recent):
Indicate any full-time or part-time position held. Note if this was summer employment
DATES EMPLOYED
EMPLOYER
TITLE
HRS./WK.
Publ
ications (Limit to 5; please start with most recent):
Resear
ch Projects (Limit to 5; please start with most recent):
Comm
unity Service: List volunteer work or community service activities without pay (Limit to 5; please start with most recent):
ORGANIZATION
YEAR(S) PARTICIPATED
TOTAL HOURS
VOLUNTEERED
Award
s/Other (Limit to 5; please start with most recent):
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 6 of 8
RECOMMENDATION FORM (1): May attach a letter to this form
To
be completed by an advisor, counselor, instructor, or work supervisor.
Recommendation forms from two separate individuals must be submitted.
Instructions for advocate/sponsor:
DO NOT include any information that would allow the selection committee to identify the applicant. Any reference to the applicant’s
name, parent/guardian’s name, employer, or any association with the Hospital for Special Care Foundation, Inc. or the Center of
Special Care, Inc. within the content of the evaluation will disqualify the application.
Please enclose the completed form in an envelope, sign your name across the seal, and return to the student.
Please do not mail this form directly to Hospital for Special Care; it must arrive with the application package to the Hospital for
Special Care Foundation, Inc.
Excellent
Good
Fair
Poor
The applicant’s self-motivation
The applicant’s commitment to school and/or
community
The applicant’s ability to seek, find and use
learning resources
The applicant’s curiosity and initiative
The applicant’s problem-solving abilities
The applicant’s respect for self and others
Ple
ase provide a brief written evaluation of this student’s academic performance and any relevant information about the student’s
contributions to the school or larger community:
Adv
ocate/Sponsor’s Name: ___________________________________ Title: _________________________
Signature: __________________________________________________ Telephone: ____________________
Busi
ness Address: _______________________________________________________________________________________
Street City State Zip
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 7 of 8
RECOMMENDATION FORM (2): May attach a letter to this form
To
be completed by an advisor, counselor, instructor, or work supervisor.
Recommendation forms from two separate individuals must be submitted.
Instructions for advocate/sponsor:
DO NOT include any information that would allow the selection committee to identify the applicant. Any reference to the applicant’s
name, parent/guardian’s name, employer, or any association with the Hospital for Special Care Foundation, Inc. or the Center of
Special Care, Inc. within the content of the evaluation will disqualify the application.
Please enclose the completed form in an envelope, sign your name across the seal, and return to the student.
Please do not mail this form directly to Hospital for Special Care; it must arrive with the application package to the Hospital for
Special Care Foundation, Inc.
Excellent
Good
Fair
Poor
The applicant’s self-motivation
The applicant’s commitment to school and/or
community
The applicant’s ability to seek, find and use
learning resources
The applicant’s curiosity and initiative
The applicant’s problem-solving abilities
The applicant’s respect for self and others
Plea
se provide a brief written evaluation of this student’s academic performance and any relevant information about the student’s
contributions to the school or larger community:
Adv
ocate/Sponsor’s Name: ___________________________________ Title: _________________________
Signature: __________________________________________________ Telephone: ____________________
Bus
iness Address: _______________________________________________________________________________________
Street City State Zip
NURSING SCHOLARSHIP APPLICATION - 2021
Last 4 digits of Social Security # ________
Hospital for Special Care Foundation www.hfsc.org 860-832-6257 Page 8 of 8
PERSONAL STATEMENT: Please describe your career goals and future aspirations as well as any experiences, skills or personal values
that will help you achieve your goals (limit to 300 words):
Explain below any unusual financial circumstances in your household. You may attach a page if space below is insufficient:
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Completed 9 March 2021

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