SDS Application Page 1

(1)

2014-2015 SDS Application Page 1

Spalding University Office of Academic Affairs

Application for Scholarships for Disadvantaged Students in the Health Professions

Tentative Funding -- Academic Year 2014-15

Applications must be received by noon on Monday, June 16, 2014

The Scholarships for Disadvantaged Students (SDS) program promotes diversity among health profession students and practitioners by providing scholarships to full-time students with financial need from

disadvantaged backgrounds, enrolled in health professions. All requirements including application information and supporting documentation as well as limitations to the Scholarships for Disadvantaged Students program are set forth by the Health Resources and Services Administration (HRSA) and as such are not amendable by Spalding University.

To be eligible to receive funding for the 2014-2015 Academic Year,

 students must be classified as graduate students in their major (MSOT, MSW, PsyD)

 students must be full-time for their major as defined by the University Catalog

 students must have submitted a FAFSA for the 2014-2015 academic year

 students must demonstrate financial need as a result of a disadvantaged background

 students must be willing to complete program fieldwork/practicum requirements in medically underserved communities (MUC)

 students must be committed to post-degree career paths working with underserved populations in primary care settings.

HRSA defines independent as being at least 24 years old and not having been listed as a dependent on parents’ income tax for 3 or more years. If a student is at least 24 years old and cannot prove independent status, then he or she would be considered dependent and the parental income will be used to determine economic disadvantage.

To apply for the Scholarships for Disadvantaged Students program, ALL students must submit the following items. Please DO NOT STAPLE. Students are responsible for making copies of all documents to be submitted; the SDS Program Office will not make copies of documentation.

 Completed Application.

 Copy of drivers’ license, birth certificate, or passport for proof of age

 Copy of IRS federal 1040 tax forms for 2011, 2012, and 2013.

o ONLY the form marked “1040” in the bottom right corner (1040A, 1040 EZ…) need be submitted. All addendums, worksheets, and schedules should be excluded.

o If you are independent of your parents, please submit YOUR tax documents. If you are considered dependent, please submit YOUR PARENTS’ tax documents.

o FAFSA documents may NOT be submitted in place of IRS documents. Incomplete applications will result in the application not being considered for funding.

The primary indicator of “disadvantaged” for the Scholarships for Disadvantaged Students program at Spalding University is economic and, therefore, preference will be given to those students who meet that criterion first. Please note that racial or ethnic minority status by itself does not qualify as “disadvantaged.”

Applications must be received by noon on Monday, June 16, 2014

Students may deliver applications to ELC 200, email applications to [email protected], or mail

applications to Judy Luther, SDS Coordinator, Spalding University, 845 S 3rd_{Street, Louisville, KY 40203.} Incomplete packets will not be accepted. Please DO NOT STAPLE. Students are responsible for making copies of all documents to be submitted; the SDS Program Office will not make copies of documentation. Students will be notified by mail of award or rejection of application. Once awards have been made, no appeals will be considered for further funding.

(2)

Spalding University Office of Academic Affairs

Application for Scholarships for Disadvantaged Students in the Health Professions

Tentative Funding -- Academic Year 2014-15

____I am currently a full-time graduate student enrolled in the degree program selected below.

____I will be a full-time graduate student in the degree program selected below.

____ Master of Science, Occupational Therapy

Cohort Start Date _______________

____ Master of Social Work

Cohort Start Date _______________

_____Psychology (PsyD)

Cohort Start Date _______________

I submitted a Free Application for Federal Student Aid (FAFSA) for academic year 2014-15.

___ Yes

___No (If no, applicant is not eligible.)

I agree to complete program fieldwork/practicum requirements in medically underserved

communities (MUC), and I am committed to working with underserved populations in

primary care settings upon completing my training program.

___ Yes

___No (If no, applicant is not eligible.)

Student Information (please print legibly)

Spalding Student ID Number: ___________________________________________________

Name: _______________________________________________________________________

Last

First

Middle Name or Initial

Mailing Address: ____________________________________________________________

Number

Street

Apt. No.

_____________________________________________________________________

City

State

Zip code

Telephone number: _____________________________________________________________

E-mail address:

_____________________________________________________________

Gender:

___Female

___ Male

(3)

Ethnicity

One of the criteria that will be used to determine scholarship eligibility is membership in one of the

traditionally under-represented groups attending higher education institutions and/or within the

student’s major, as defined by HRSA. Please indicate your ethnic origin/race below:

Are you of Hispanic/Latino descent?

___ Yes

___ No

Please select one or more of the following:

_____ American Indian or Alaska Native – A person having origins in any of the original peoples of

North/South and/or Central America and who maintains a tribal affiliation or community

attachment.

_____ Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia

or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea,

Malaysia, Pakistan, Philippine Islands Thailand, or Vietnam.

_____ Black or African American – A person having origins in any of the black racial groups of

Africa.

_____ Native Hawaiian or other Pacific Islander – A person having origins in any of the original

peoples of Hawaii, Guam, Samoa or other Pacific Islands.

_____ White – A person having origins in any of the original peoples of Europe, the Middle East or

North Africa.

Individual Characteristics

Please select a response for each of the following:

_____ Yes

_____ No

Are you from a disadvantaged background as defined below?



Comes from an environment that has inhibited the individual from obtaining the knowledge,

skill, and abilities required to enroll in and graduate from a health professions school, or from

a program providing education or training in an allied health profession

OR



Comes from a family with an annual income below a level based on low income thresholds

according to family size published by the U.S. Bureau of Census, adjusted annually for

changes

_____ Yes

_____ No

1

st

generation college student

(neither parent has completed a 4-year degree)

_____ Yes

_____ No

1

st

_{generation graduate degree-seeking student}

(neither parent has completed a graduate degree

_____ Yes

_____ No

Are you from a rural residential background?

If yes, please indicate county, state, and zip code: ________________________________________

_____ Yes

_____ No

Are you a veteran? If yes, please select status:

(4)

Financial Information/Eligibility

HRSA defines independent as being at least 24 years old and not having been listed as a dependent on parents’ income tax for 3 or more years. If a student is at least 24 years old and cannot prove independent status, then he or she would be considered dependent and the parental income will be used to determine economic disadvantage.

Please select one of the following and submit appropriate tax forms with application. DO NOT STAPLE. Include ONLY legible 1040 forms.

_____ I am 23 years of age or younger, so according to HRSA I am considered a dependent of my parents. Thus, I am submitting copies of my parents’ 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums).

_____ I am 24, 25, or 26 years of age, but I have been listed as a dependent on my parents’ tax returns during the last 3 years. Thus, I am considered a dependent of my parents as defined by HRSA and I am submitting copies of my parents’ 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums).

_____ I am at least 24 years old and considered an independent student because I have NOT been claimed as a dependent for at least 3 years. Thus, I am submitting copies of my 2011, 2012, and 2013 IRS Federal 1040 tax forms (no addendums).

_____ I am at least 24 years old and considered an independent student because I have NOT been claimed as a dependent for at least 3 years. I did not file income tax returns for one or more of 2011, 2012, 2013, so I am submitting verification from the IRS stating such. I understand that it is my responsibility to visit the IRS office in person to obtain the necessary forms stating I did not file.

As reported on parents’ or student’s 2013 Federal 1040 tax form:

_____ Number of _____ Number of $_____________ (AGI)

Exemptions Dependents Adjusted Gross Income

The table below lists the income levels that meet the 2012 economic disadvantage criterion.

Please place an X next to your eligibility

level to match # of exemptions.

Size of Parents’ or

Student’s family *

Income

Level **

1 $22,980

2 $31,020

3 $39,060

4 $47,100

5 $55,140

6 $63,180

7 $71,220

8 $79,260

* Includes only dependents listed on Federal Income tax forms. **Adjusted gross income for calendar year 2013

(5)

Spalding University Office of Academic Affairs

Application for Scholarships for Disadvantaged Students in the Health Professions

Tentative Funding -- Academic Year 2014-15

Summary of Eligibility – Because the need of the eligible Spalding students is greater than the maximum amount of available SDS funds, each program will rank students based on Financial Information/Eligibility – Amount of unmet need – as the Primary Indicator. All criteria in the application will be reviewed with consideration also given to under-represented minority status, 1st_{generation college student , and 1}st

generation graduate degree-seeking student .

Post-Degree Career Path (please select all that apply)

_____ After graduation, I intend to practice in a primary care setting. _____ After graduation, I intend to practice in a medically underserved area.

_____ After graduation, I intend to practice in a rural setting (areas outside of cities and towns). By signing this statement, I agree to the following:

To the best of my knowledge, the information I have provided in this application is true and accurate. If asked, I will provide proof of accuracy of any response I have made on this application. I understand my full application is to be reviewed by administrative and council members of the Scholarships for Disadvantaged Students in the Health Professions grant program.

I understand that to be eligible

 I must be enrolled full-time as a graduate student in my degree program (MSOT, MSW, PsyD) as defined by the University Catalog.

 I must have submitted a FAFSA for academic year 2013-14.

I agree to complete program fieldwork/practicum requirements in medically underserved communities. If I receive a scholarship, I understand I must maintain full-time enrollment as defined by the University Catalog during the 2013-2014 academic year.

To retain this scholarship, I must maintain good standing according to the policies of my degree program as defined in the University Catalog.

If I receive a scholarship, I agree to respond to surveys requesting additional information to fulfill HRSA reporting requirements.

If I fail to abide by all parts of this statement, I will relinquish this scholarship immediately.