Southeast Scholarship Application

NOTE: Please include your first and last name in all files submitted online and use proper Upper Case/lower case when completing this application. Scholarship Award Luncheon held the 1st Friday in August – All recipients are highly encouraged to attend to accept their award.

Contact Information

First Name

Middle Name

Last Name

Student ID or last 4 digits of Social Security number

FAFSA EFC number

Maiden Name/other names used

Current Street Address

Address

City

State

Zip Code

Home Address (if different from Current Street Address)

Address

City

State

Zip Code

Home Phone

Cell Phone

Do you work?

Name of Employer

Current Title / Position

Are you employed with Mercy?

Are you a student at Southeast Missouri State University?

If yes, are you one of the following at Southeast Missouri State University?

Do you expect to receive other financial aid?

Are you currently enrolled in SoutheastHEALTH College of Nursing & Health Sciences?

Program Information

Course of Study

If you chose “other” for level of study, please indicate level.

Level of Study

If you chose “other” for level of study, please indicate level.

Educational Institution Attending

School Street Address

Address

City

State

Zip Code

Enrolled as a Full-Time student?

Length of Program

Anticipated graduate date (m/y)

GPA

Financial Need

Clearly explain your need for financial assistance and how it will help you in achieving your career goals. (600-character limit, which equals about 200 words).

Career Goals

Clearly explain your need for financial assistance and how it will help you in achieving your career goals. (600-character limit, which equals about 200 words).

Application Certification

I certify the information contained in this application is true, complete and correct to the best of my knowledge and that all funds will be used for enrollment expenses related to the program in which I am entering or enrolled. I hereby authorize the release of personal,scholastic and financial information related to my educational status to Mercy Health Foundation Southeast from any academic institution I have attended in the past and any academic institution in which I am enrolled or may be enrolled as a future student. I further waive my right to view any reference letters submitted on my behalf.*

Yes No

Submission Instructions

Submitting on or before May 31st

Yes No

Satisfactory completion and submission of scholarship application
Submit by mail or email: Acceptance letter or equivalent documentation from the school the applicant is attending.
Submit by mail or email: Current FAFSA report.
Submitted by mail or email individually from each of the two references on the required Reference Form: References may not be relatives, but may be a current or past employer, instructor, coach, volunteer supervisor, or minister and must be submitted on the required Scholarship Reference Form. References must be able to attest to the character and qualifications of the applicant.
Submitted by Registrar’s Office after spring semester; ordered by student before May 31st: Transcript including final spring grades must be ordered before by May 31st and must be sent directly from the Registrar’s office to Mercy Health Foundation Southeast.

Call 573.519.4920 or email: [email protected] with any questions.

Two different references required:

• References can be sent by mail or email.

• References must be submitted directly from the person providing the reference.

• References cannot be relatives, but may be a current or former employer, instructor, coach, volunteer supervisor or minister.

•References must be able to attest to the character and qualifications of the applicant.

Transcript:

• A transcript with final spring grades must be ordered from the attending registrar’s office before May 31.

• Transcripts must be mailed directly from the registrar’s office to:

Mercy Health Foundation Southeast

1849 Broadway

Cape Girardeau, MO 63701

Call 573.519.4920 or email: [email protected] with any questions

For more information on Mercy scholarships, contact Mercy Health Foundation Southeast at 573.519.4920. Deadline for all scholarship applications is May 31st of each year.