2025 Memorial Hospital Foundation Scholarship Application

Scholarship Application Form

Application Deadline - March 15, 2025
Read and follow the instructions carefully prior to submitting your application click here. All winners will be notified on or before the end of May 2025.
Read and Understand the instructions.*

Yes, I have
If selected, you will be asked for documentation to support the data you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
Please select the scholarship(s) you are applying for.

Bethany Volz Medical Staff Scholarship (High School Graduate of MHHCC service area; Any healthcare field)Doris A. Ackerman & Family Nursing Scholarship (Dubois County graduates pursuing nursing degree)Mabel L. Kuebler Nursing Endowment (Dubois County graduates pursuing nursing degree)Mildred E. Schwinghammer Nursing Scholarship (Dubois County graduates pursuing nursing degree)St. Joseph Auxiliary Scholarship (Southridge HS graduate; Any healthcare field)Kathleen M. Tempel Nursing Scholarship (Any southwest Indiana county graduate pursuing nursing degree)Memorial Hospital Auxiliary Magy Clark Volunteer Scholarship (Current/Active MHHCC Volunteer; Any field of study)Lou Jerger Memorial Healthcare Scholarship (Graduate of MHHCC Service area; Any healthcare field)Memorial Hospital Foundation County Scholarship (Any high school graduate that lives in Crawford, Daviess, Dubois, Martin, Orange, Perry, Pike & Spencer county; Any healthcare field)Memorial Hospital Foundation HOSA Scholarship (Health Occupations Students of America)Memorial Hospital and Health Care Center Medical Staff ScholarshipSue Strange & Amy Todd Healthcare Scholarship
For a more detailed description of the scholarships, please click here.

If you are applying for the Memorial Hospital Nursing Scholarships (for nursing students entering their fourth/final year of education) or the Tonya Heim Nursing Scholarship, there is a separate application form for those. Please visit the Foundation website to access those applications.

Please ensure all requested documents are attached prior to submitting application!
I. Personal Data:

Tell us about yourself
Full Name*

First NameLast Name
Birthdate:*

MonthDayYear
Age
Mobile No. :*

Area CodePhone Number
E-mail :*
Where the confirmation will be send to
Home Address :*

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence:*
County of Residence
Gender:

MaleFemalePrefer not to answer
Mother/Guardian Name:
Answer as applicable.
Father/Guardian Name:
Answer as applicable.
Step-Mother/Guardian Name:
Answer as applicable.
Step-Father/Guardian Name:
Answer as applicable.
Other:

I do not wish to disclose any parental/guardian information.
II. Academic Information
Status at the time of application:

I will graduate high school in spring 2025I will be an incoming college freshman graduating high school prior to 2025I have attended college but have less than 32 college credit hoursI have attended college but have at least 32 or more college credit hoursI am a GED graduate with no college credit hours
Are you a first generation college student ?

Yes, I am the first among my parents or grandparents to attend college.No, either my parents or grandparents have attended college.
High School Attended:
If "Other" chosen above, please list High School here:
Year of High School Graduation or GED:
Most recent cumulative GPA:
College you plan to attend:
Have you been accepted?
Intended college major: *
Years required to complete this degree:
What is your Career Objective:*

0/300
III. ACT / SAT Information:
Year you took the ACT:
ACT composite (overall) score?
Year you took the SAT:
SAT Math Score:
SAT Evidence-Based Reading/Writing Score:
SAT Total Score:
IV. For Students Currently Enrolled in Secondary Education :

Please complete if you have already started your college/secondary education.
Approximate credit hours completed by May 2025:
Current GPA:
College activities, honors, offices held, etc.:
IV. Household Information:
Father/Guardian Occupation:
Father/Guardian Employer:
Mother/Guardian Occupation:
Mother/Guardian Employer:
Number of children listed as dependents (including you):
Please list any siblings in a post-high school educational program, and the school they attend:
If you answered the question above, do your parents/guardians provide financial support for these siblings and their education?

YesNoOther
V. Financial Information
Federal Adjusted Gross Income (AGI) as listed on your parents most recent Federal Form 1040

Below $30,000$30,001 to $50,000$50,001 to $75,000$75,001 to $100,000$100,001 to $150,000Above $150,000
Federal Adjusted Gross Income (AGI) as listed on YOUR (the applicant's) most recent Federal Form 1040

Below $30,000$30,001 to $50,000$50,001 to $75,000$75,001 to $100,000$100,001 to $150,000Above $150,000
Financial contributions from parents/guardians:
Please list scholarship name, amount, and if it's a multi=year scholarship.
Please list all scholarships and amounts that you have already received or will receive:
Please list scholarship name, amount, and if it's a multi=year scholarship.
c) Are you currently employed?

YesNo
Employer Name
Will you be working while attending college?*

YesNo
Are you (the applicant) receiving financial support for your education from a parent/guardian?

YesNoUnknown
Does your family have any extraordinary expenses you'd like to share? Please explain.
Describe any other of your work activities (e.g. working on family farm, helping at home, church work, etc.)
VI. Estimated Academic Expenses
Tuition and Fees:
Room and Board:
Other Specialized Fees, if applicable:
If you have none, please leave blank.
Please explain
VII. Individual Student Profile:
High School activities in which you have participated, and how many years of participation: (e.g. clubs, sports, etc.)
(e.g. Drama Club (3 years), Varsity Basketball (2 years), Future Farmers of America (4 years)
If currently enrolled in college, please list any college activities: (e.g. clubs, sports, etc.)
(e.g. Drama Club (3 years), Varsity Basketball (2 years), Future Farmers of America (4 years)
Awards, Honors, or Letters you have received: (includes academic, athletic, community and/or workplace)
Leadership positions or offices held: (includes academic, athletic, community and/or workplace)
Services you have rendered to your school/community or volunteer work:
Community organizations to which you belong:
Exceptional or original talents you feel you have demonstrated in the areas of art, music, science, literature, mathematics, or industrial arts:
Principal strengths as a person:
Principal academic strengths:
Do you plan to return to Dubois County, or your county of residence, to work after obtaining your degree?

YesNo
Do you have a relationship with anyone affiliated with Memorial Hospital and Health Care Center?

YesNo
If yes, Name and Position:
If you are a current MHHCC Volunteer, where are you currently assigned?
Department or Location
If you are a current MHHCC volunteer, how many hours have you completed as of date of application?
Number of hours
VIII. Essay
Your essay should be 250 words or less. Be creative! You should address in your essay: your college goals and why you've decided on your chosen major, what you intend to do with your education, and why a scholarship is important to you. Please do not use the phrase: "...because I have always wanted to help people..." Include any experiences that make you uniquely worthy of scholarship consideration.
Essay:

0/500
IX. Other Required Uploads
Please attach the following to complete your application:

1. Attach a copy of your transcript showing information for three and one-half years of high school and/or transcripts of your past four college semesters.

2. Attach three signed reference letters:

- One personal reference (from a church leader, friend, club leader, etc.)

- One from a past employer (a boss or supervisor) or one demonstrating community invovlement (from a civil club, local organization, etc.)

- One from a teacher or administrator

3. If already accepted into a college program, include acceptance letter.

4. If you are chosen as a scholarship recipient, we would like to include your photo in the publications announcing your award. Photos will not be distributed to the scholarship committee, and will be used only after awards are chosen for promotional use. This is optional.
High School Transcript Upload:

Browse Files

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College/Secondary Education Transcript Upload:

Browse Files
Only upload if applicable. Cancelof
Reference Letter #1:

Browse Files

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Reference Letter #2:

Browse Files

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Reference Letter #3:

Browse Files

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College acceptance letter, if applicable:

Browse Files

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Applicant headshot photo: (optional - this is only used for scholarship announcements. Selection committee does not see the photo.)

Browse Files

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Please ensure all attachments have uploaded completely prior to submitting.
VIII. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
The Memorial Hospital Foundation is committed to equal opportunity in employment and education. The Memorial Hospital Foundation does not discriminate in any program or activity on the basis of race, color, religion, gender, age, national origin, disability, marital status, or any other protected class.
Should be Empty:

Scholarship Application Form

I. Personal Data:

II. Academic Information

III. ACT / SAT Information:

IV. For Students Currently Enrolled in Secondary Education :

IV. Household Information:

V. Financial Information

VI. Estimated Academic Expenses

VII. Individual Student Profile:

VIII. Essay

IX. Other Required Uploads

Please ensure all attachments have uploaded completely prior to submitting.

VIII. Applicant's E-Signature