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Submission Deadline: Friday, April 9, 2021

Instructions: This is a fillable PDF. Please complete all fields, then save a copy, renaming the file with your first and last name. Email the application and all required documents to smcf@memorialcare.org.

*Required field

Applicant Information

*Date of Application

*First and Last Name

*Address

*City, State Zip

*Primary Phone

*Primary Email

*Is this your first time applying for an SMCF Scholarship?

If not the first time, provide the year(s) you previously applied.

*Marital Status *Number of Dependents

Employment Information

*Employee ID Number

*Years Employed at Saddleback Medical Center

*Department(s)

*Title/Position

*Full-time or Part-time? *Permanent?

*Immediate Supervisor

*Service Director

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Financial Information

*Total Household Income for Last Calendar Year (including your income)$

*Cost per Class/Unit (Please indicate whether measured by class or unit.)$ per

*Total Estimated Tuition Cost for Upcoming School Year (July 2021 – June 2022) (Books, course materials, room and board, or any other fees are NOT eligible for reimbursement.)$

*Expected Amount of Tuition Reimbursement from MemorialCare Employee Benefit(Please check with Human Resources for the amount for which you are eligible.)$

*Expected Loan Forgiveness from MemorialCare Employee Benefit(Please check with Human Resources for the amount for which you are eligible.)$

*Other Financial Assistance Toward Education Expenses(e.g., scholarships, grants, or fee waivers for this school year) $

Academic Information

*College/University

*Academic Degree You Are Pursuing (e.g., BSN, MSN, MBA)

Field of Emphasis (if applicable)

*Enrollment Date (dd/mm/yyyy)

*Projected Graduation Date (mm/yyyy)

*Student ID

*Status (e.g., freshman, 2nd-year grad student)

*Number of Courses You Plan to Take from July '21 – June '22

*Number of Units You Plan to Earn from July '21 – June '22

*Current or Most Recent Cumulative GPA (required unless you are a new student this upcoming school year)

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Please list ALL previous colleges/universities attended, starting with the most recent. If you have no previous college history, please write N/A.

*College/University

*Major

*Start Date (mm/yyyy)

*End Date (mm/yyyy)

*GPA

College/University

Major

Start Date (mm/yyyy)

End Date (mm/yyyy)

GPA

College/University

Major

Start Date (mm/yyyy)

End Date (mm/yyyy)

GPA

*Do you plan to transfer to another college/university to complete your current degree?

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Authorization and Attestation

I attest that I have read the eligibility requirements and procedures for this scholarship application and that all information provided in this application is correct to the best of my knowledge.

I understand that falsification of any part of this application will result in my immediate disqualification for a scholarship award.

I understand that I must remain a permanent (full- or part-time) employee of Saddleback Medical Center for the entire academic year (July 2021 – June 2022), in order to remain eligible for receiving scholarship funds. I understand that if my education plan or employment status changes before or during this time frame, I must notify Saddleback Medical Center Foundation, and my scholarship may be revoked.

I agree to provide completed reimbursement request forms, records of my tuition expenses, and proof of my final grade(s) no later than 60 days following completion of each course taken between July 2021 and June 2022 if I wish to receive scholarship funds (up to a total of the maximum amount listed in my scholarship award letter). I understand that if I miss a deadline or fail to meet the grade requirement of a C or higher for a course, I will not receive money for that course. I understand that I will still have the opportunity to receive scholarship funds for courses taken later in the year, if I meet the requirements.

I understand and agree that, should I be awarded a scholarship, I must attend the Scholarship Awards Ceremony on July 14, 2021, or provide written explanation no later than 48 hours before the ceremony, explaining the nature of the emergency preventing me from attending. I further understand and agree to write a letter of appreciation to the Saddleback Medical Center Foundation Scholarship Committee and/or the specific donor (if I am awarded a donor-named scholarship).

I hereby authorize the release of all information provided in this application to the Scholarship Committee and/or other individuals involved in the selection of scholarship recipients. I hereby authorize the release of any performance evaluations or related information from my personnel file or by my service director or supervisor to the abovementioned committee or individuals, with the understanding and promise that such information will be kept in the strictest confidence.

Applicant Signature

I agree to the statements listed above, and I understand that my typed, electronic signature is legallybinding, just as if I had signed a paper document.

Save and rename this PDF with your first and last name. Email this application with all required documents to smcf@memorialcare.org by April 9, 2021.