CHIA Student Scholarship Application

CHIA Student Scholarship Application
For more information about eligibility and full requirement details, visit http://californiahia.org/page/scholarship-programs

Deadline for submitting applications (including the Application Form and all required documents) is March 1.
Name*

First NameLast Name
Credentials
AHIMA/CHIA ID Number*
CHIA Membership Status*

Emerging Professional MemberActive Member
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
Name of College/University*
Type of degree*
Name of Degree (e.g. Health Information Technology)*
Expected HIA/HIT Program Graduation Date*

MonthDayYear
Program GPA*
Written essay, of no more than 500 words, responding to the following two questions:
- Describe your educational and/or career goals in the health information profession
- Describe how receiving a CHIA Scholarship will assist you in meeting your educational and/or career goals in the health information profession
Written Essay (PDF only)*

Upload a File

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Transcripts (PDF only)*

Upload a File

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Program Director Validation (PDF only)

Upload a File
Program Director Validation is required, and can be emailed directly. Cancelof
Please be aware that a reference request will be automatically sent via email. Kindly ensure that you have informed the individual in advance and they may need to check their junk/spam folder for the email.
Reference #1 Name*

First NameLast Name
Reference #1 Phone Number
Reference #1 Email*
example@example.com
Reference #2 Name*

First NameLast Name
Reference #2 Phone Number
Reference #2 Email*
example@example.com
Reference #3 Name

First NameLast Name
Reference #3 Phone Number
Reference #3 Email
example@example.com
Reference #4 Name

First NameLast Name
Reference #4 Phone Number
Reference #4 Email
example@example.com
I certify that the information submitted with this application is accurate and I authorize CHIA to validate its accuracy:*

Clear
Signature
Should be Empty: