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Midland Health Scholarship Application Form Page

* Denotes required field

*Applicants must be accepted into the program prior to applying for scholarship.

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email *

Phone Number *

Midland College Id# *

Are you legally authorized to work in the United States? *

Yes
No

Do you now, or will you in the future, require sponsorship for an employment visa status to work legally in the United States?* *

Yes
No

Which program are you seeking scholarship assistance? *

Certified Nurse Aide (CNA)
Licensed Vocational Nurse (LVN)
LVN to RN Transition Program
Associate Degree (RN)
Pharmacy Technician
Phlebotomy
Radiologic Technologist
Respiratory Care
Sonography

Have you received your letter of acceptance for the program? *

Yes
No

What is your estimated start and end date?

Start date: *

End Date: *

Please submit your acceptance letter with this application *

Do you now, or have you ever been employed by Midland Memorial Hospital? *

Yes
No

Dates of employment

Start Date *

End Date *

Department *

Manager Name *

Certification

To the best of my knowledge, the information provided on this application is correct and complete. I agree that Midland College and Midland Health have my permission to verify any and all information. I understand that applying for the Midland Health Scholarship Program affirms my wish to be considered but does not guarantee selection into the Midland Health Scholarship Program or an award of a Midland College scholarship. If accepted into the Midland Health Scholarship Program, I understand that my academic record will be shared with the Midland Health Human Resource Department per semester and upon my certification or degree completion.

Print Name *

Signature *

Captcha *

You are unable to proceed with the application process at this time. Please reach out to your Midland College Admissions Department for further information. You are encouraged to resubmit your application once you have received your letter of acceptance into the program.