Health Information Technology Scholarship Application Form

This application form is required to be considered for the Health Information Technology Scholarship. All question must be answered completely or your application may be delayed.

Term for which application is being made: Please rank your preference number under the term, first choice = 1.

Fall - September:

Winter - November:

Spring - February:

Summer - June:

Year for which application is being made: *

BASIC INFORMATION

Last Name: *

First Name: *

Middle Initial:

Sex: *

Male

Female

Street Address: *

City: *

State: *

Zip: *

Email Address: *

Phone Number: *

EDUCATIONAL BACKGROUND

Are you a high school graduate?: *

Yes

Have you attended a post-secondary school or university?: *

Yes

Degree/major earned: *

Currently attending: *

ACADEMIC & CAREER PLANS

In which field are you currently employed: *

Health Care

IT Field

Number of Years: *

Name of current employer: *

Job Title: *

Healthcare or IT work experience/skills not acquired through formal education: *

Previous Health or IT experience: *

By submitting this application it indicates that you understand and agree to the following statements.

I certify that the above statements are true and correct.

I understand that I may be denied admission or be dismissed from the College by submitting false or misleading information.

Last Modified: March 9, 2011

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Health Information Technology Scholarship Application Form

Madison College School Offices

School of Agriscience and Technologies

Health Information Technology (HIT)