Behavioral Health / Registered Nurse Student Loan Assistance Fund

Employment Information

Applicant must be employed as registered nurse/school nurse or behavioral health counselor with Creative Health Services or school district within 10-mile radius of Pottstown. (Preference will be given to those working in the Boyertown Area School District.)
Name of Employer
Place of Employment*
Location/Building(s)*
Roles/Responsibilities
Number of Hours Worked per Week*
HR Contact Name*

First NameLast Name
HR Contact Phone Number*
Please enter a valid phone number.
Hire Date From*

MonthDayYear
Date
Hire Date To

MonthDayYear
Date

Education Debt

Must be no less less than $10,000 in student loan debt.
Estimate of total outstanding educational debt from all loan holders*
Dollar Amount
Attach current statement(s) for loans sufficient to show at least $10K in student loan debt. *

Cancelof
Note that loans must be with a student loan provider.

Short Answer

Attach Answer. No Longer than one page typed.
What inspired you to work in this field (nursing or behavioral health)?*

Cancelof

Certification
I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I hereby consent fully to verification of any and all information included in this application. I understand that any willfully false representation of information is sufficient cause for rejection of this application. I have fully disclosed all outstanding loan debt and am not currently in default of any service or loan obligation.
Applicant’s Signature (Full Legal Name)*

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Date*

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Date
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Behavioral Health/ Registered NurseStudent Loan Assistance Fund