1) APPLICANT DATA____________________________________________________________ Last Name First Name Middle Initial

____________________________________________________________ Permanent Home Residence (Street Address)

____________________________________________________________ City County State ZIP Code

____________________________________________________________ Daytime Telephone

____________________________________________________________ Date of Birth SSN (last four)

_____________________________________________________________

E-mail Address

How long have you been a resident of DeKalb County?________________

Is an immediate family member employed by Kishwaukee Hospital?

Yes NoIf yes:

Family member name:___________________________________________

Relationship:__________________________________________________

Education

Professional Goal:_______________________________________________

Name of your health-related program:________________________________

Expected academic level as of Sept. 2021:____________________________

College or University you will be attending:____________________________

Grade Point Average:__________ Expected Graduation Date:____________

At college, will you be participating in an NCAA-administered sport?

Yes No

If yes, which sport?______________________________________________

Northwestern Medicine Kishwaukee Hospital Auxiliary Scholarship Application

SUBMISSION DEADLINEScholarship application and all original documents must be postmarked no later than Monday, May 3, 2021. Send completed application packet to:

2) PERSONAL STATEMENTApplicants must submit a brief personal profile, not to exceed one typewritten page. This essay should include relevant information about your career goals and qualifications. This is your opportunity to present yourself to the scholarship selection committee.

3) TRANSCRIPT INFORMATIONOfficial transcripts from all academic institutions (high school and college) are required for all applicants, to be mailed directly to the hospital. High school transcripts are required only if you graduated within the last ten years. Prior scholarship recipients need only update your records with your most recent transcripts.

4) PROOF OF ACCEPTANCEFirst-time applicants need to provide an official letter of acceptance from their educational institution or the applicant's major on their transcript.

5) LETTERS OFRECOMMENDATIONFirst-time applicants need to include two letters of recommendation.

6) EDUCATION AND EXPERIENCEInclude a Word document or PDF with your responses to the Education and Experience Questionnaire included at the end of this application.

7) RESOURCES AND NEEDInclude a Word document or PDF with your responses to the Resources and Need assessment included at the end of this application.

8) CERTIFICATIONIn submitting this application, I certify that the information provided is complete and accurate to the best of my knowledge, and that I intend to complete my course of study.

___________________________________________ Applicant’s Signature

Northwestern Medicine Kishwaukee HospitalAttn: Auxiliary Scholarship Committee1 Kish Hospital DriveDeKalb, IL 60115

SUBMISSION GUIDELINES

Am I Eligible?Eligible applicants for the Kishwaukee Hospital Auxiliary scholarship must meet the following criteria:

• Have an official letter of acceptance into a collegelevel health-related program and intend to be afull-time student, or

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Legal address is in DeKalb County.An immediate family member is employed by Kishwaukee Hospital.Are a volunteer in good standing through the Kishwaukee Hospital volunteer program with at least 20 hours of service.

How Do I Apply?• Complete the application and all the necessary

documents and mail to the address shown on the form.

• Please include all items in one envelope.

• Have your school send original transcripts to the address shown on the form.

How are Recipients Selected?Scholarships are awarded on the basis of:

• Financial need and family circumstance.• Academic record as indicated on school transcript, activities, and additional information provided by applicant.• Educational and career goals as expressed in personal statement.

Are currently enrolled as a full time student in ahealth-related program at the college level.Students in general course of studies programs (i.e.pre-med, general education courses, liberal arts,etc.) are not eligible.One of the following criteria must also be met:

What Are My Obligations?Kishwaukee Auxiliary Scholarship recipients are required to supply the scholarship administrator with current transcripts and promptly notify the administrator of any changes of address, school enrollment, or other relevant information.

Scholarship recipients acknowledge that Kishwaukee Hospital and its Foundation may release their name, photo, and personal information to others in order to promote the Kishwuaukee Hospital Auxiliary scholarship to the media and donors.

Deadline for submission is May 3, 2021

Send your completed application form, personal statement, letters of recommendation, proof of acceptance, education and experience questionnaire, and resources and needs assessment to:

Northwestern Medicine Kishwaukee HospitalAttn: Auxiliary Scholarship Committee1 Kish Hospital DriveDeKalb, IL 60115

Scholarship Information• Checks will be mailed directly to the recipient's

school. The school need not be an Illinoisinstitution.

• If recipient drops out of school or changes theirmajor to a non-health program, funds must bereturned commensurate with the school yearremaining.

• Official proof of acceptance to a school of highereducation must accompany this application or anofficial college transcript which indicates theapplicant's major.

• Applicants will be notified by May 24 on thestatus of their application.

• Please direct all questions to Cheryl Lorden atcheryllorden@gmail.com.

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• Previous scholarship recipients may reapply to be considered for a 2021 scholarship.

EDUCATION AND EXPERIENCE QUESTIONNAIRE

Complete the following questions about your educational background, professional experience, and volunteer history and submit with your application.

Applicant's educational history, including high school, if you graduated within the last 10 years:

School Location Degree Received Year Graduated____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Honors and Awards Received____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Employment History

Employer Dates of Employment________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Volunteer Services

Agency Dates of Service____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Have you volunteered at Kishwaukee Hospital? Yes_______ No_______

If yes, when and in what service area?________________________________________________________________

Should you be a scholarship recipient, what is the address where funds are to be mailed (Be sure to provide name of institution and specific department/office where funds are to be sent).____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

RESOURCES AND NEED ASSESSMENT

Complete the following questions about your financial resources and expenses for the 2021-2022 academic year and submit with your application.

Resources

Applicant:__________________________________

Spouse:____________________________________

Relative Contributions:_______________________

Savings:___________________________________

Loans:_____________________________________

Scholarships/Grants:________________________

Other:_____________________________________

Total Financial Resources:____________________

Expenses

Tuition and Fees:____________________________

Room/Board:_______________________________

Books & Supplies:__________________________

Personal:__________________________________

Other:_____________________________________

Total Expenses:_____________________________

Do you contribute to the support of any other person(s) or have other financial obligations? If so, explain in awritten statement. (Example: Current loans—amount and when due.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________