LeadingAge Kentucky Scholarship Form

Submission Deadline: June 5, 2013

Guidelines:

LeadingAge Kentucky each year awards one (1) $2,000.00 Scholarship. All applicants must complete the application form and the form must be submitted to the LeadingAge Kentucky office and must be accompanied by a recommendation by the facility administrator or the applicant’s direct supervisor or both. The winner will be announced at LeadingAge Kentucky’s Annual Conference Awards Luncheon, September 18, 2013.

Criteria:

Nominee must be employed for one year by a LeadingAge Kentucky member
Entry application must include a recommendation by an administrator or direct supervisor (or both)
Recipient must use the scholarship award for tuition and/or books in classes pertaining to health care, management or other fields associated with health care such as bookkeeping, social work, or recreational therapy.

Type of School: Kentucky College or University
Term of Scholarship: One (1) year
Amount of Scholarship: $2,000.00

^* = Information Required

Nominee Information

^* Name of Nominee:
^* Title/Degree:
^* Address of Nominee:
^* City:
^* State:
^* Zip:
^* Affiliation, Organization:
Telephone:
Fax:

Individual Submitting Nomination

^* Name:
^* Title:
^* Organization:
^* Address:
^* City:
^* State:
^* Zip:
^* Telephone:
Fax:
Email:
^* Administrator's Email for Approval:

Scholarship Application

^* Nominee Home Address:
^* City:
^* State:
^* Zip:
Phone #:
High School Attended:
Year of Graduation:
College or Univ. you are/will be attending:
Address:
City:
State:
Zip:
^* Status:	Freshman Sophomore Junior Senior Other (enter below)
Status: Other:
Major:
Degree:
Plans for Advanced Degree:	Yes No
^* Recommendation:	Please attach recommendation of facility administrator or direct supervisor or both.
^* Short Essay:	Please attach a short essay (150 words or less) describing your personal and career goals, and any significant experiences or circumstances which led to this application.
^* Previous Award:	Have you previously received an award from the LeadingAge KY Scholarship Fund? Yes No
Previous Award:	If yes, when and how much? To the best of my ability, I attest that the above information is true.

2501 Nelson Miller Parkway
Louisville, KY 40223
502-992-4380
502-992-4390 - FAX

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