Walsh Hospital District Rural Health Transformation Program (RHTP) Educational Scholarship Application

SECTION 1: APPLICANT INFORMATION

Full Name: (required)

Mailing Address: (required)

City, State, Zip: (required)

Phone Number (required)

Email Address (required)

Are you currently employed by Walsh Hospital District? (required)

Yes

If yes, department or position

SECTION 2: EDUCATIONAL PROGRAM

Select the type of education or training for which you are applying: (required)

Certified Nursing Assistant (C.N.A) training and certification

Licensed Practical Nurse (LPN) program

LPN-to Registered Nurse (RN) bridge program

Healthcare certification or credentialing

Emergency Medical Technician (EMT) Certification

Other healthcare-related education or training

If other, please specify:

Name of School or Training Provider: (required)

Program Name (required)

Program Start Date: (required)

Expected Completion Date: (required)

SECTION 3: SCHOLARSHIP REQUEST

Total estimated cost of the program: (required)

Amount of scholarship requested: (required)

Please identify the expenses for which you are requesting assistance: (required)

Please specify other expenses:

Have you received or applied for other financial assistance for this program? (required)

Yes

If yes, please describe the assisance and amount, if known:

SECTION 4: EDUCATIONAL AND CAREER GOALS

Please briefly explain why you are pursuing this education or training and how it will help strengthen healthcare services in Walsh or surrounding rural communities. (required)

SECTION 5: RURAL HEALTHCARE SERVICECOMMITMENT

The applicant acknowledges that scholarship assistance is funded through Walsh Hospital District's Rural Health Transformation Program (RHTP) workforce-development initiative.

By applying, the applicant understands that:

Scholoarship awards are subject to eligibility requirements, available funding, and District approval.

Approved funds may be used only for allowable educational expenses.

Recipients will be required to complete a five-year service commitment.

The District will communicate the applicable service requirements, including the required period and qualifying employment, before scholarship funds are awarded.

A separate Educational Scholarship and Service Commitment Agreement may be required before funds are disbursed.

The applicant understands that submitting this application does not guarantee a scholarship award.

SECTION 6: APPLICANT CERTIFICATION

I certify that the information provided in this application is true and accurate to the best of my knowledge. I authorize Walsh Hospital District to request reasonable documentation to verify my enrollment, educatinal expenses, and eligibility for scholarship assistance.

I understand that scholarship funds must be used for approved educational expenses and that I may be required to sign a separate scholarship agreement outlining the applicable rural healthcare service commitment and any related requirements before receiving funds.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Printed Name: (required)

Date: (required)

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