Continuing Healthcare Education Scholarship Application

    Personal Information

    First Name

    Last Name

    SSN

    Mailing Address

    Email Address

    Home Phone

    Work Phone

    Cell Phone

    Length of residence/work in Lake Chelan area

    Course Information

    Course/Program you plan to take (no acronyms)

    Administered by (attach copy of registration form)

    Date of course/program

    Location of course/program

    Number of C.E. Credits

    Deadline for registration

    Registration for Program/Course Expense

    Meals included?
    YesNo

    Cost of Books

    Other Fees

    Have you received a Bragg Scholarship previously?
    YesNo

    If yes, what year?

    Educational Background: Please list the school, location, dates of study, field of study and GPA.

    Employment History: Please list Employer, Address, Dates and Responsibilities.

    Is course required by employer?
    YesNo

    Is course required for certification in your current position?
    YesNo

    Is this an online course/program?
    YesNo

    Why are you applying for these funds?

    Explain your career goals and how this course/program will benefit health care:

    Are you available for a personal interview?
    YesNo

    Sign & Date

    I certify that to the best of my knowledge the information contained in this application is true and correct. I understand this application will not be considered for review unless it is complete, signed and dated. I also understand that no materials will be returned. Sign below using your mouse or touchpad.

    Today's Date:

    If application is approved the check should be payable to the Administrator, Lake Chelan Community Hospital or other. If asking for personal reimbursement, attach receipt of payment.