Caromont Regional Medical Center Auxiliary

CaroMont Regional Medical Center Auxiliary Gertrude Clinton Health Career Scholarship

In 1971, a revolving loan fund of $2,000 was established by the Gaston Memorial Hospital Auxiliary. Following Mrs. Gertrude Clinton’s death, the fund was changed to a scholarship in her memory. Mrs. Clinton, widow of Dr. Roland Clinton, served as Gaston County Social Services Director, Gaston Memorial Hospital Personnel Director and Gaston Memorial Hospital Auxiliary President. The fund has grown to more than $40,000 annually and has assisted hundreds of students in a variety of health-related careers. The purpose of this scholarship is to encourage medical and health-related professionals to practice their specialties at CaroMont Regional Medical Center or in Gaston County.

Scholarship Guidelines, Process, and Timeline

The CaroMont Regional Medical Center Auxiliary is thrilled to be able to offer financial assistance to individuals seeking degrees in health-related majors. Applicant Criteria:  Scholastic Achievement- proof of cumulative 3.0 grade point average for previous academic performance  Financial need  Evidence of student leadership and community service  Applicant officially accepted into a health-related program of study at a college or hospital study program.  Previous scholarship recipients, prior to 2015, who still meet original qualifications may re-apply annually a) Submit renewal application by March 1, 2016 b) Enclose copy of college (school) transcript and must maintain a C average grades or above c) No interview will be required  Scholarship recipients from 2015 to the present a) Must submit renewal application by March 1, 2016 b) Must enclose copy of college (school) transcript and must maintain a 3.0 GPA c) Must go through the rest of the application process d) They are not automatically renewed

Required Information: All information below is required and must be received by Traci Agnew, Volunteer Coordinator, on or before March 1, 2016. 1. Completed application 2. Resume, including extracurricular activities, leadership, and volunteerism listing – with years of involvement 3. Most recent official academic transcript 4. Proof of application, acceptance or attendance at an accredited college or university healthcare program. Scholarship funding will not be released until proof of acceptance is provided. 5. Two (2) completed reference forms 6. Recent photo 7. Interview required General Rules  If a scholarship recipient discontinues his/her education or changes from a health career field, the balance of the scholarship must be returned to the CRMC Auxiliary Scholarship Fund and designated for emergency use.  If a scholarship recipient dies while studying under the Gertrude Clinton Scholarship Fund, any balance must be returned to the CRMC Auxiliary.  In the event of a scholarship recipient becoming ill or disabled, any balance must be returned to the CRMC Auxiliary. Special consideration will be given to renewal applicants.  Scholarship funds shall be used only for payment of tuition, required fees, institution equipment, training materials, books, room and board and other educational-related expenses.  The amount of scholarship awards shall be variable, dependent upon the needs of the applicant; however, the total scholarship fund awards shall not exceed the annual scholarship fund budget. Additional funds may be requested by the scholarship chairman as needed. Submit all documentation to the following: Traci Agnew Volunteer Coordinator CaroMont Regional Medical Center 2525 Court Drive Gastonia, NC 28054 Applications will be available Friday, Jan. 1, 2016 – Tuesday, March 1, 2016. Applications received after March 1 will not be considered. Interviews with qualifying applicants will be scheduled on April 6, 7, or 8, 2016. Scholarship recipients will be announced the first week of May, 2016. For more information, please contact Traci Agnew at 704-834-2256 or [email protected]. CaroMont Regional Medical Center Auxiliary Gertrude Clinton Health Career Scholarship Scholarship Application Please Print Name: Phone: Physical Address: Contact E-mail: Parents’ E-mail:(if applicant is a minor) Mailing address: (if different) Parents’ Names:(if applicant is a minor) Father’s Employer:(if applicant is a minor) Mother’s Employer(if applicant is a minor)

ASSOCIATION WITH CAROMONT HEALTH Current Employee: _____ Yes ______No Department: Supervisor: Phone: Family member of employee: ______Yes ______No Department: Supervisor: Current volunteer: ______Yes ______No Family member of volunteer ______Yes ______No: Employee/Volunteer’s Name: Relationship to applicant: EDUCATIONAL EXPERIENCE Name of last school attended (High School or college): Highest grade or degree completed: Name of school you plan to attend during the next academic year: City/State: Have you been accepted into a health-related field? ______Yes ______No What is your intended major? What are your future career plans?

List other scholarships/grants for which you have applied for the upcoming academic year and the amount of money received: Scholarship/grant: Amount:

FINANCIAL ANALYSIS: If you are dependent on your parent(s), what is their annual income? If you are not dependent on your parent(s), what is your annual income? What is the total annual cost of your college/university? (books, tuition, lodging, etc.)

Please explain your financial need, along with any unusual circumstances:

Why have you decided to pursue a career in healthcare? ______

How would this scholarship enhance your healthcare career? ______I certify that all information given in this application is true and complete to the best of my knowledge. In submitting this application, I authorize investigation of all statements contained therein, and it is understood and agreed that any misrepresentation by me in the application will be sufficient cause for cancellation of this application. I authorize the CRMC Auxiliary to make any investigation deemed necessary and release the party contacted from all liabilities and damages for issuing same.

Applicant Name: (Please Print) ______

Applicant Signature: ______Date: ______

Parent/Legal Guardian Signature: ______Date: ______(if applicant is under 18 years of age) CaroMont Regional Medical Center Auxiliary

News Release Permit

I hereby authorize CaroMont Health to release news information and/or photographs of me to the news media.

I agree to hold CaroMont Health free of liability and harmless for any action arising from the use or publication of these photographs and/or news information.

Print Full Name

Signature

Please print full name of parents, guardian or spouse (as appropriate)

Please attach photo here: CaroMont Regional Medical Center Auxiliary

Personal Reference Form (Please print.)

To be completed by applicant:

Applicant’s Name: ______

Admitted/Applied to Health Career Program at: ______

Under the provisions of the Family Educational Rights and Privacy Act of 1974, you may decide whether letters of reference written at your request are to be held confidential or whether they are to be available for your personal inspection. Check one of the following statements and place your signature in the space provided, so that the reference will be advised of your choice.

____ Confidential File: I grant permission for this letter of recommendation to be held confidential by the CaroMont Regional Medical Center Auxiliary.

_____Open File: I retain the choice of having letters of reference available to me.

Applicant Signature: ______Date: ______

NOTE: You may be contacted by phone concerning this reference. CaroMont Regional Medical Center Auxiliary

Personal Reference Form

To be Completed by Reference: You may wish to make additional comments in a letter. If you do so, please attach your letter to this form. Please return this form to the applicant no later than Monday, February 15, 2016 in a sealed envelope with your signature on the back flap.

Applicant’s Name: ______

Knowledge of applicant:

_____ This student has been enrolled in my class(es).

_____ I was this student’s major professor or academic advisor.

_____ While I have not taught or advised the applicant, I have known this person for _____ year(s).

Scholastic Evaluation: In comparison with other students in the same academic area. I rate this applicant:

__ _Superior (upper 5%) ___ Good (upper 25%) ___ Below Average

___Very Good (upper 10%) ___ Average (upper 50%) Recommendation: Considering this applicant’s academic record, special abilities, ambition and determination, please indicate your level of recommendation of this applicant.

Academic Special Ambition & Record Abilities Determination I recommend strongly for: ______

I recommend for: ______

I recommend with reservation: ______

I cannot recommend for: ______

Please state reasons for your assessment of the applicant’s qualifications.

______

Name of reference: (Please print) ______

Home Phone: ______Work Phone: ______

Title: ______Institution: ______

Address: ______

Reference Signature: ______Date: ______