Scholarship Fix Please enable JavaScript in your browser to complete this form. - Step 1 of 3Section 1 - Personal InfoDate Of ApplicationMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---New JerseyPennsylvaniaDelawareStateZip CodeGender *MaleFemaleDay Phone Number *Alternate Phone NumberEmail *Date Of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place Of Birth *How long have you been a resident of New Jersey, Pennsylvania or Delaware? *Are you a high school graduate? *YesNoDo you possess a GED? *YesNoHave you ever received a Preferred Home Health Care & Nursing Services Scholarship? *YesNoAs a previous winner of the PHHC Scholarship you are ineligible for another award.Do you speak another language? *YesNoWhat Languages Do You Speak?Have you ever worked for Preferred Home Health Care & Nursing Services? *YesNoNextSection 2 - Narrative SummaryExplain in fewer than 500 words what inspired you to attend nursing school.Summary *Upload Narrative Summary Click or drag a file to this area to upload. If you choose to upload your narrative summary, please write "See Attached" in the above field.School of Nursing *School Contact To Verify EligibilityName of Contact *Phone of Contact *Email of Contact *School Address *Address Line 1Address Line 2City--- Select state ---New JerseyPennsylvaniaDelawareStateZip CodePlease Select One *Full Time StudentPart Time StudentDate Of Enrollment In Present Nursing Program *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Expected Date Of Graduation *Have you transferred to this school from another nursing program? *YesNoName of previous school.NextSection 3 - Certiciation Of StatementI certify that all of the information on this scholarship application is true and complete to the best of my knowledge. I realize that information from this application will be used to determine my scholarship eligibility. If asked by the Nursing Scholarship Advisory Committee, I agree to provide documentation verifying any information on this application.Applicant Signature * Clear Signature Name *FirstLastDate *NameSubmit
