We ask that both you and your nominee complete these forms online at:

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Dear Administrator/Executive Director:

Following, you will find this year’s HCANJ Foundation Nurse Scholarship application

packet. We offer two awards of $2,000 each in both the LPN and RN categories.

However, please be aware that the Foundation reserves the right to award either one or

two scholarships in each category dependent on the number and caliber of nominations

received.

Please distribute this information to those eligible staff in your building who have

been accepted into a nursing program. The forms included must either be typed or

completed online. The link below will provide you with PDF documents that can

be filled out online, saved, and printed out for mailing.

We ask that both you and your nominee complete these forms online at:

http://www.hcanj.org/emails/NurseScholarship.pdf

Your attention to our deadline of April 15 would be most appreciated as we cannot

accept late or incomplete applications.

If you have any questions, please don’t hesitate to contact me by phone at

(609) 890-8700 or e-mail at

pattie@hcanj.org

.

Sincerely,

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Dear Scholarship Applicant:

Thank you for your interest in the Health Care Association of New Jersey Foundation’s Nurse Scholarship Program.

The purpose of this program is to assist qualified persons who wish to further their education toward becoming an RN or LPN in the long term health care profession.

Applicants must:

be a New Jersey resident;

be accepted to an accredited LPN or RN program for the coming academic year;

o A letter from the Director of the Professional Nursing Program, stating that you have

matriculated into the Nursing Program, or are enrolled in pre-nursing and listing the semester you will begin the actual Nursing Program, must accompany the application. Please note that letters of acceptance, transcripts or grade progress reports will not fulfill this requirement. currently be employed in a member facility for at least 12 consecutive months, full or part time; o part time is defined as at least fifteen hours per week. The scholarship is open to facility

employees only - family members of an employee are not eligible. be sponsored by a member facility with two letters of reference; o one from the facility administrator/executive director/owner; and o one from another professional or academic source.

In addition, each of these references must fill out the included Recommendation Form. volunteer 25 hours per year in a member facility while in school if not employed by a member facility during that time;

be willing to pledge that, upon successful completion of the nursing program, they will practice their nursing skills in a member long-term care facility for at least one year; and,

complete the entire Application Form, which includes a brief statement regarding his/her interest and experience in long term care; include the above-mentioned letters of reference with completed Recommendation Forms (each in sealed envelope, per instructions on the Recommendation form); sign and include the Acknowledgement, Release and Financial Agreements, and have the facility Administrator sign the Certification of Eligibility.

Please be aware of the requirement to complete the forms online and then print out for mailing. The easier it is for the judges to read your documents, the better it is for everyone.

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over-Letter to Applicant – Nurse Scholarship Page Two

All applications must be received in the HCANJ Executive Office on or

before April 15. Incomplete or faxed applications cannot be accepted.

PLEASE NOTE: INCOMPLETE OR FAXED APPLICATION PACKAGES WILL BE RETURNED TO THE FACILITY.

Four scholarships can be awarded – two for students studying to become a Licensed Practical Nurse and two to students studying to become a Registered Nurse. Each will allow tuition and/or course- related expenses up to $2,000 per year, for a maximum of two years. Scholarship funds will be made payable to the student and school by the quarter or semester and continue only if school reports show the student to be successful in his/her efforts to achieve his/her RN/LPN degree. The Registrar of the school must verify eligibility; therefore, applicants should see the Registrar of their school about signing a release allowing us to obtain the appropriate information without delay.

Again, we thank you for your interest and wish you much luck with your career.

Health Care Association of New Jersey Foundation

Please do not staple or bind any part of the application or supporting

documentation. Thank you.

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PLEASE COMPLETE THIS FORM ONLINE

HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION RN/LPN SCHOLARSHIP APPLICATION

Please check which scholarship you are applying for: RN ___ LPN ___ Applicant’s Name __________________________________________________________________________ Home Address_____________________________________________________________________________ Telephone Number _________________________________________________________________________ Name of HCANJ Member Facility where you are employed_________________________________________ Date employment began at facility ____________________________________________________________ Name of school you have been accepted to:______________________________________________________

Address of school __________________________________________________________________________ Starting date___________________________ Anticipated date of graduation_________________________ Attach a letter from the Director of the Professional Nursing Program stating that you have matriculated into the Nursing Program, or that you are enrolled in pre-nursing, and listing the semester you will enter the actual Nursing Program.

If required by the school of your choice, have you passed a minimum basic skills test in preparation for admission? Yes ___ No ___

Will it be necessary for you to take remedial courses prior to entering the Nursing Program? Yes ___ No ___ What special training related to long term care have you had?

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RN/LPN Scholarship Application Form Page Two

Please describe your future professional plans.

Have you received any scholarship or tuition support from any other source(s)? If so, please specify the source(s). Do not include requests for financial aid.

In the space provided, please describe the following: any experiences you have had in long term care, either personally or professionally; your interest in long term care as a profession; and what unique challenges you believe the long term care profession holds.

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PLEASE COMPLETE ONLINE

HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP ADMINISTRATOR RECOMMENDATION FORM

(to accompany RN/LPN Scholarship Application)

We appreciate your recommendation of the applicant. Please complete this form and place it in a sealed

envelope along with the requested Letter of Reference. The applicant must return it with his/her application, which must be received in the HCANJ Executive Office on or before April 15.

Name of Applicant _________________________________________________________________________ Name of Administrator ______________________________________________________________________ Name of Facility___________________________________________________________________________ Address of Facility _________________________________________________________________________ Phone Number of Facility____________________________________________________________________

How would you rate the applicant on the following:

Low Average High No Opinion Maturity ( ) ( ) ( ) ( ) Sensitivity ( ) ( ) ( ) ( ) Commitment to nursing profession ( ) ( ) ( ) ( ) Ability to communicate ( ) ( ) ( ) ( ) Leadership ( ) ( ) ( ) ( )

On your organization letterhead, please provide a letter of reference that describes why

you believe this applicant would be a worthy recipient of a HCANJ Foundation nursing

scholarship and attach it to this form.

___________________________________________

Signature

___________________________________________

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PLEASE COMPLETE ONLINE

HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP RECOMMENDATION FORM

(to accompany RN/LPN Scholarship Application)

We appreciate your recommendation of the applicant. Please complete this form and place it in a sealed

envelope along with the requested Letter of Reference. The applicant must return it with his/her application, which must be received in the HCANJ Executive Office on or before April 15.

Name of Applicant _________________________________________________________________________ Name of Reference _________________________________________________________________________ Address of Reference _______________________________________________________________________ Phone Number of Reference __________________________________________________________________ Position of Reference _______________________________________________________________________ In what capacity have you known the applicant? __________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ How would you rate the applicant on the following:

Low Average High No Opinion Maturity ( ) ( ) ( ) ( ) Sensitivity ( ) ( ) ( ) ( ) Commitment to nursing profession ( ) ( ) ( ) ( ) Ability to communicate ( ) ( ) ( ) ( ) Leadership ( ) ( ) ( ) ( )

On your organization letterhead, please provide a letter of reference that describes why

you believe this applicant would be a worthy recipient of a HCANJ Foundation nursing

scholarship and attach it to this form.

___________________________________________

Signature

___________________________________________

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PLEASE COMPLETE ONLINE

HEALTH CARE ASSOCIATION OF NEW JERSEY FOUNDATION NURSING SCHOLARSHIP CERTIFICATION OF ELIGIBILITY

(to be completed by the facility administrator and accompany RN/LPN Scholarship Application)

Member Facility Name ___________________________________________________________ Administrator/Executive Director/Owner Name _______________________________________ Facility Address ________________________________________________________________ Facility Phone __________________________________________________________________

Applicant’s Name _______________________________________________________________ Applicant’s Position at facility _____________________________________________________ Number of hours worked per week in facility _________________________________________ Date of applicant’s employment ____________________________________________________ Has the applicant worked at your facility for at least 12 consecutive months? ________________

Certification

The above named facility wishes to sponsor the indicated applicant for this year’s HCANJ Foundation Nursing Scholarship Program. I have met with the applicant and am satisfied that he/she is eligible to apply for the scholarship. I will notify HCANJ immediately should the applicant become ineligible.

If chosen to receive a scholarship, I will accompany the applicant to the HCANJ monthly business meeting at which scholarship recipients will be introduced to and honored by the association membership.

____________________________________

Administrator Signature

____________________________________ Date

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ACKNOWLEDGEMENT, RELEASE, AND FINANCIAL AGREEMENT

I hereby acknowledge that _________________________________________________ (facility) is sponsoring me as an applicant for a Health Care Association of New Jersey Foundation Scholarship. I have completed all the necessary forms and certify that the information I have given is factual. If I am selected as a Scholarship recipient, the Health Care Association of New Jersey has my permission to use the information on the application forms, any biographical data provided, and/or any photographs provided or taken, in their publications and other media.

I understand that repayment of any monies granted to me by the Health Care Association of New Jersey Foundation’s scholarship will be required should I, for some reason, not be able to complete the LPN/RN course, or should I not be able to work in a HCANJ member facility for the one-year service period after successfully completing the LPN/RN course.

____________________________________________

Signature of Applicant

____________________________________________

Print Name

____________________________________________

Date

Check that all required forms are completed: _____ Typed or printed application form

_____ Letter of matriculation from the Director of the Professional Nursing Program (Letters of acceptance, transcripts or grade reports will not fulfill this requirement)

_____ Letter of reference from Administrator _____ Recommendation Form from Administrator _____ Additional letter of reference

_____ Additional Recommendation Form

_____ Signed Acknowledgement, Release & Financial Agreement _____ Signed Certification of Eligibility from Administrator

Mail completed package to:

HCANJ

Attn: Pattie Tucker

4 AAA Drive, Suite 203

Hamilton, NJ 08691-1803

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