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<p><strong><span style=\'font-size: 18px;\'>Scholarship Application</span></strong></p><p>When you apply for and are awarded a scholarship from our scholarship fund you receive philanthropic dollars to support your pursuit of a career in the nursing or allied healthcare professions. Multiple scholarships are available to deserving students and Concord Hospital employees pursuing careers primarily in nursing and, on a limited basis, to students pursuing careers in various qualifying fields of allied health care. To be considered, applicants must submit the <strong>online application and all supplemental documentation</strong><strong>&nbsp;no later than April 21, 2024.</strong> Applications for which the supplemental documents have not been received will not be considered. Scholarship awards typically range from $500 - $3,000, and award recipients are notified by mid-June.</p><div class=\'form-group\'><label for=\'FormField1_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>First Name:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField2_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Last Name:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label  class=\'control-label  \'>Are you a Concord Hospital employee?<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Yes\' required data-msg-required=\'This field is required.\' name=\'checkbox74\' id=\'FormField74_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'right\' data-export-label=\'Are_you_a_Concord_Hospital_employee_\' ><label for=\'FormField74_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>Yes</label></div><div class=\'flow\'><input type=\'radio\' value=\'No\' required data-msg-required=\'This field is required.\' name=\'checkbox74\' id=\'FormField74_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'right\' data-export-label=\'Are_you_a_Concord_Hospital_employee_\' ><label for=\'FormField74_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>No</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField3_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Address:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField3_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField3_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Address_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField54_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>City:<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField54_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField54_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control  rolloverField\' style=\'width: auto\' required data-msg-required=\'This field is required.\' data-export-label=\'City_\' ><option value=\'\' selected>( Please Select )</option><option value=\'Alexandria\'>Alexandria</option><option value=\'Allenstown\'>Allenstown</option><option value=\'Alton\'>Alton</option><option value=\'Andover\'>Andover</option><option value=\'Ashland\'>Ashland</option><option value=\'Barnstead\'>Barnstead</option><option value=\'Belmont\'>Belmont</option><option value=\'Boscawen\'>Boscawen</option><option value=\'Bow\'>Bow</option><option value=\'Bradford\'>Bradford</option><option value=\'Bristol\'>Bristol</option><option value=\'Canterbury\'>Canterbury</option><option value=\'Center Barnstead\'>Center Barnstead</option><option value=\'Center Harbor\'>Center Harbor</option><option value=\'Chichester\'>Chichester</option><option value=\'Concord\'>Concord</option><option value=\'Concord\'>Concord</option><option value=\'Danbury\'>Danbury</option><option value=\'Deering\'>Deering</option><option value=\'Dunbarton\'>Dunbarton</option><option value=\'Epsom\'>Epsom</option><option value=\'Franklin\'>Franklin</option><option value=\'Gilford\'>Gilford</option><option value=\'Gilmanton\'>Gilmanton</option><option value=\'Hebron \'>Hebron </option><option value=\'Henniker\'>Henniker</option><option value=\'Hill\'>Hill</option><option value=\'Hillsboro\'>Hillsboro</option><option value=\'Hooksett\'>Hooksett</option><option value=\'Hopkinton\'>Hopkinton</option><option value=\'Laconia\'>Laconia</option><option value=\'Loudon\'>Loudon</option><option value=\'Meredith\'>Meredith</option><option value=\'Moultonborough\'>Moultonborough</option><option value=\'New Hampton\'>New Hampton</option><option value=\'Pembroke/Suncook\'>Pembroke/Suncook</option><option value=\'Penacook\'>Penacook</option><option value=\'Pittsfield\'>Pittsfield</option><option value=\'Salisbury\'>Salisbury</option><option value=\'Sanbornton\'>Sanbornton</option><option value=\'Sandwich\'>Sandwich</option><option value=\'Warner\'>Warner</option><option value=\'Washington\'>Washington</option><option value=\'Weare\'>Weare</option><option value=\'Webster\'>Webster</option><option value=\'Windsor\'>Windsor</option><option value=\'N/A - See Next\'>N/A - See Next</option></select><div class=\'formHelp rolloverHelp\'>These are cities in Concord Hospital&#39;s primary service area.</div></div></div><div class=\'form-group\'><label for=\'FormField68_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>If you do not live in Concord Hospital&#39;s primary service area but graduated from a high school in its service area within the past five years, or are a Hospital employee, enter the city you live in:</label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField6_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Country:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField7_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Zip Code:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField8_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Number of Years at this Address:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField11_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Email Address:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField9_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Primary Phone:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField10_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Secondary Phone:</label><div>\
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</div></div><p><strong>EDUCATION INFORMATION</strong></p><div class=\'form-group\'><label for=\'FormField32_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>High School Name, City, State &amp; Zip Code:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField33_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Graduation Year:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField34_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>GED/HiSet Year:</label><div>\
<input type=\'text\' name=\'FormField34_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField34_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-mini  rolloverField\' value=\'\'   data-export-label=\'GED_Hi_Set_Year_\'  placeholder=\'\'  />\
<div class=\'formHelp rolloverHelp\'>Only if applicable.</div></div></div><p><strong>To be eligible to apply you must:</strong></p><ul><li>Be a resident within Concord Hospital&apos;s service area for a period of at least one year, as of the application deadline, have graduated* from a high school within the Hospital&rsquo;s service area within the past five years, or be employed by Concord Hospital;&nbsp;</li><li>Be accepted into an accredited nursing or allied healthcare profession program and successfully complete one semester before funding is awarded.</li></ul><p>*Graduated from high school or passed the General Education Development (GED)/Hi-Set test.</p><p><strong>Students choosing to apply as an allied healthcare applicant must be enrolled in a specialized program that results in immediate eligibility for registration, certification or licensure to provide high quality patient care services (i.e., no broad-based programs such as Biology, Health Education, etc.).</strong></p><p><strong>COLLEGE/UNIVERSITY INFORMATION</strong></p><div class=\'form-group\'><label for=\'FormField12_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College Attending in 2024-2025:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField12_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField12_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'College Attending in 2024-2025: is required.\' data-export-label=\'College_Attending_in_2024_2024_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField56_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Length of Program:<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField56_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField56_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'This field is required.\' data-export-label=\'Length_of_Program_\' ><option value=\'\' selected>( Please Select )</option><option value=\'Four years\'>Four years</option><option value=\'Two years\'>Two years</option><option value=\'Graduate\'>Graduate</option></select></div></div><div class=\'form-group\'><label for=\'FormField14_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College Address:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField15_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College City:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField16_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College State:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField17_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College Zip Code:<span class=\'fb-required\'>*</span></label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField18_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College Phone:</label><div>\
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</div></div><div class=\'form-group\'><label for=\'FormField19_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>College ID Number:</label><div>\
<input type=\'text\' name=\'FormField19_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField19_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small \' value=\'\'   data-export-label=\'College_ID_Number_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label  class=\'control-label  \'>In September 2024, I will be in my:<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'1st year\' required data-msg-required=\'In September 2024, I will be in my: is required.\' name=\'checkbox57\' id=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'right\' data-export-label=\'In_September_2024_I_will_be_in_my\' ><label for=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>1st year</label></div><div class=\'flow\'><input type=\'radio\' value=\'2nd year\' required data-msg-required=\'In September 2024, I will be in my: is required.\' name=\'checkbox57\' id=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'right\' data-export-label=\'In_September_2024_I_will_be_in_my\' ><label for=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>2nd year</label></div><div class=\'flow\'><input type=\'radio\' value=\'3rd year\' required data-msg-required=\'In September 2024, I will be in my: is required.\' name=\'checkbox57\' id=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\' class=\'right\' data-export-label=\'In_September_2024_I_will_be_in_my\' ><label for=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\'>3rd year</label></div><div class=\'flow\'><input type=\'radio\' value=\'4th year\' required data-msg-required=\'In September 2024, I will be in my: is required.\' name=\'checkbox57\' id=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_4\' class=\'right\' data-export-label=\'In_September_2024_I_will_be_in_my\' ><label for=\'FormField57_01eda1b9-1ac0-4433-a0f0-f97630554cc2_4\'>4th year</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>If in graduate school, I will be in my:</label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'1st semester\'  name=\'checkbox80\' id=\'FormField80_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'right\' data-export-label=\'If_in_grad_school_I_will_be_in\' ><label for=\'FormField80_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>1st semester</label></div><div class=\'flow\'><input type=\'radio\' value=\'2nd semester or beyond\'  name=\'checkbox80\' id=\'FormField80_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'right\' data-export-label=\'If_in_grad_school_I_will_be_in\' ><label for=\'FormField80_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>2nd semester or beyond</label></div></fieldset></div></div></div><div class=\'form-group\'><label  class=\'control-label  \'>I will attend:<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'Full-time (12 credits or more)\' required data-msg-required=\'This field is required.\' name=\'checkbox23\' id=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'right\' data-export-label=\'I_will_attend_\' ><label for=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>Full-time (12 credits or more)</label></div><div class=\'flow\'><input type=\'radio\' value=\'Part-time (6-11 credits)\' required data-msg-required=\'This field is required.\' name=\'checkbox23\' id=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'right\' data-export-label=\'I_will_attend_\' ><label for=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>Part-time (6-11 credits)</label></div><div class=\'flow\'><input type=\'radio\' value=\'Less than part-time (Fewer than 6 credits)\' required data-msg-required=\'This field is required.\' name=\'checkbox23\' id=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\' class=\'right\' data-export-label=\'I_will_attend_\' ><label for=\'FormField23_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\'>Less than part-time (Fewer than 6 credits)</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField24_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Graduate Date:</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField24_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField24_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm-dd-yy\' data-export-label=\'Graduate_Date_\'  data-rule-dateFormat=\'MM-DD-YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField25_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Post Graduate Date:</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField25_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField25_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm-dd-yy\' data-export-label=\'Post_Graduate_Date_\'  data-rule-dateFormat=\'MM-DD-YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField26_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Masters Date:</label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField26_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField26_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm-dd-yy\' data-export-label=\'Masters_Date_\'  data-rule-dateFormat=\'MM-DD-YYYY\' style=\'float: left;\' /></div></div></div><div class=\'form-group\'><label for=\'FormField55_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Degree Type:<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField55_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField55_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'This field is required.\' data-export-label=\'Degree_Type_\' ><option value=\'\' selected>( Please Select )</option><option value=\'Diploma\'>Diploma</option><option value=\'Certificate\'>Certificate</option><option value=\'Associates\'>Associates</option><option value=\'Bachelors\'>Bachelors</option><option value=\'Masters\'>Masters</option><option value=\'Doctorate\'>Doctorate</option></select></div></div><div class=\'form-group\'><label for=\'FormField29_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Program of Study:<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField29_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField29_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'This field is required.\' data-export-label=\'Program_of_Study_\' ><option value=\'\' selected>( Please Select )</option><option value=\'Accredited Nursing Program \'>Accredited Nursing Program </option><option value=\'Art Therapists\'>Art Therapists</option><option value=\'Cardiovascular Technologists\'>Cardiovascular Technologists</option><option value=\'Clinical Laboratory Technicians\'>Clinical Laboratory Technicians</option><option value=\'Clinical Laboratory Technologists\'>Clinical Laboratory Technologists</option><option value=\'Dosimetrists\'>Dosimetrists</option><option value=\'Dietitians\'>Dietitians</option><option value=\'Music Therapists\'>Music Therapists</option><option value=\'Occupational Therapists\'>Occupational Therapists</option><option value=\'Physical Therapists\'>Physical Therapists</option><option value=\'Physician Assistants\'>Physician Assistants</option><option value=\'Pharmacists\'>Pharmacists</option><option value=\'Radiation Therapists\'>Radiation Therapists</option><option value=\'Radiologic Technologists\'>Radiologic Technologists</option><option value=\'Respiratory Therapists\'>Respiratory Therapists</option><option value=\'Social Workers\'>Social Workers</option><option value=\'Speech Language Pathologists\'>Speech Language Pathologists</option><option value=\'Surgical Technologists\'>Surgical Technologists</option><option value=\'Ultrasongraphers\'>Ultrasongraphers</option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group\'><label for=\'FormField75_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>If other, please indicate program of study:</label><div>\
<textarea rows=\'10\' name=\'FormField75_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField75_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-small\'   data-export-label=\'If_other_indicate_program_of_study\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label  class=\'control-label  \'>I will live:<span class=\'fb-required\'>*</span></label><div class=\'Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'On campus\' required data-msg-required=\'This field is required.\' name=\'checkbox30\' id=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'right\' data-export-label=\'I_will_live_\' ><label for=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>On campus</label></div><div class=\'flow\'><input type=\'radio\' value=\'Off campus\' required data-msg-required=\'This field is required.\' name=\'checkbox30\' id=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'right\' data-export-label=\'I_will_live_\' ><label for=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>Off campus</label></div><div class=\'flow\'><input type=\'radio\' value=\'At home and commute to campus\' required data-msg-required=\'This field is required.\' name=\'checkbox30\' id=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\' class=\'right\' data-export-label=\'I_will_live_\' ><label for=\'FormField30_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\'>At home and commute to campus</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField36_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Tuition &amp; Fees:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField36_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField36_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small  rolloverField\' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Tuition___Fees_\'  placeholder=\'\'  />\
<div class=\'formHelp rolloverHelp\'>Estimate your educational cost for the next school year.</div></div></div><div class=\'form-group\'><label for=\'FormField37_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Room &amp; Board:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField37_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField37_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Room___Board_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField38_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Other Expenses:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField38_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField38_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small  rolloverField\' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Other_Expenses_\'  placeholder=\'\'  />\
<div class=\'formHelp rolloverHelp\'>(Please specify, e.g. transportation):</div></div></div><div class=\'form-group\'><label for=\'FormField39_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Total Cost:<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField39_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField39_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'Total_Cost_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField41_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Provide all scholarships and grants already received for the next school year.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField41_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField41_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-large rolloverField\' required data-msg-required=\'This field is required.\'  data-export-label=\'Provide_all_scholarships_and_grants_already_received_for_the_next_school_year_\'  placeholder=\'\'></textarea>\
<div class=\'formHelp rolloverHelp\'>Include Source of Funding and Dollar Amount</div></div></div><div class=\'form-group\'><label for=\'FormField73_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Provide all anticipated scholarships and grants not yet received for the next school year.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField73_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField73_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-medium\' required data-msg-required=\'This field is required.\'  data-export-label=\'Provide_all_anticipated_scholarships_and_grants_not_yet_received_for_the_next_school_year_\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField43_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>What is your Expected Family Contribution (EFC) as reported on your Student Aid Report (FAFSA)?<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField43_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField43_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'What_is_your_Expected_Family_Contribution__EFC__as_reported_on_your_Student_Aid_Report__FAFSA__\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField72_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>How much will your family be paying toward your education for the next school year?<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField72_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField72_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'How_much_will_your_family_be_paying_toward_your_education_for_the_next_school_year_\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField44_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>How much current student loan debt do you have?<span class=\'fb-required\'>*</span></label><div>\
<input type=\'text\' name=\'FormField44_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField44_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-small \' value=\'\'  required data-msg-required=\'This field is required.\' data-export-label=\'How_much_current_student_loan_debt_do_you_have_\'  placeholder=\'\'  />\
</div></div><p><strong>ADDITIONAL INFORMATION</strong></p><p>All applications are reviewed by the Trust Scholarship Fund Committee which includes nurses, educators, allied health professionals and others.<br><br>In order to know you better, in an essay of no more than 500 words, please explain why you want to become a nurse or allied healthcare professional. <strong>Essays of greater than 500 words will not be considered.</strong><br><br>If you have received a prior Trust Scholarship award, please do not resubmit a prior essay unless it has been modified to reflect your further experience and growth. <strong><br></strong></p><div class=\'form-group\'><label for=\'FormField45_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Essay Submission<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField45_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField45_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-large\' required data-msg-required=\'Essay Submission is required.\'  data-export-label=\'Essay_Submission\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField69_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>In no more than 200 words, please let us know what other compelling information you would like the committee to consider? This may include personal circumstances, family circumstances, financial challenges, work experiences, volunteer experiences or other important information that support why you should be awarded a scholarship. Please be concise. Compositions of greater than 200 words will not be considered.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField69_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField69_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-medium\' required data-msg-required=\'In no more than 200 words, please let us know what other compelling information you would like the committee to consider? This may include personal circumstances, family circumstances, financial challenges, work experiences, volunteer experiences or other important information that support why you should be awarded a scholarship. Please be concise. Compositions of greater than 200 words will not be considered. is required.\'  data-export-label=\'Compelling_information_200_words\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label for=\'FormField76_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>List any special recognitions and/or awards received throughout the past four years.<span class=\'fb-required\'>*</span></label><div>\
<textarea rows=\'10\' name=\'FormField76_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField76_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control textarea-medium\' required data-msg-required=\'List any special recognitions and/or awards received throughout the past four years. is required.\'  data-export-label=\'List_Any_Recognitions_Awards\'  placeholder=\'\'></textarea>\
</div></div><div class=\'form-group\'><label  class=\'control-label  hidden-label\'>Authorization:<span class=\'fb-required\'>*</span></label><div><div><div class=\'flow Chkbx rolloverField\'><input type=\'checkbox\' value=\'I hereby authorize the employers, educational institutions, and references named above to provide Concord Hospital Trust with information and opinions concerning my educational background, previous work experience, and work-related qualifications, behavior, and character. I understand that the information and opinions disclosed by these organizations and individuals will be used by Concord Hospital Trust to evaluate my candidacy for the Concord Hospital Trust Scholarship. I hereby release each individual reference and each of my current and former educators and employers, and their respective agents and employees, from any and all claims and liabilities related to the information and opinions they provide to Concord Hospital Trust, and I hereby release Concord Hospital Trust, its employees and agents, from all claims and liabilities related to its use of the information and I certify the information I have provided in this application is true and complete to the best of my knowledge. I understand that any false statement, misrepresentation, or omission may be cause for rejection of my application or, revocation of scholarship.\' required data-msg-required=\'This field is required.\' name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField64_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_64\' id=\'FormField64_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'fo-right-margin-5\' data-export-label=\'Authorization_\' ><label for=\'FormField64_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>I hereby authorize the employers, educational institutions, and references named above to provide Concord Hospital Trust with information and opinions concerning my educational background, previous work experience, and work-related qualifications, behavior, and character. I understand that the information and opinions disclosed by these organizations and individuals will be used by Concord Hospital Trust to evaluate my candidacy for the Concord Hospital Trust Scholarship. I hereby release each individual reference and each of my current and former educators and employers, and their respective agents and employees, from any and all claims and liabilities related to the information and opinions they provide to Concord Hospital Trust, and I hereby release Concord Hospital Trust, its employees and agents, from all claims and liabilities related to its use of the information and I certify the information I have provided in this application is true and complete to the best of my knowledge. I understand that any false statement, misrepresentation, or omission may be cause for rejection of my application or, revocation of scholarship.</label></div></div></div></div><div class=\'form-group\'><label for=\'FormField52_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Signature:</label><div>\
<input type=\'text\' name=\'FormField52_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField52_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium  rolloverField\' value=\'\'   data-export-label=\'Signature_\'  placeholder=\'\'  />\
<div class=\'formHelp rolloverHelp\'>Your electronic signature shall have the same force and effect as your written signature.</div></div></div><div class=\'form-group\'><label  class=\'control-label  hidden-label\'>Consent:</label><div><div><div class=\'flow Chkbx rolloverField\'><input type=\'checkbox\' value=\'I hereby grant full permission to the Concord Hospital Trust to use my likeness in all media including, but not limited to, photographs or video and audio recordings for any legitimate purpose, should I be granted scholarship funds.\'  name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField63_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_63\' id=\'FormField63_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'fo-right-margin-5\' data-export-label=\'Consent_\' ><label for=\'FormField63_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>I hereby grant full permission to the Concord Hospital Trust to use my likeness in all media including, but not limited to, photographs or video and audio recordings for any legitimate purpose, should I be granted scholarship funds.</label></div></div></div></div><div class=\'form-group\'><label for=\'FormField61_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Signature :</label><div>\
<input type=\'text\' name=\'FormField61_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField61_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium  rolloverField\' value=\'\'   data-export-label=\'Signature__\'  placeholder=\'\'  />\
<div class=\'formHelp rolloverHelp\'>Your electronic signature shall have the same force and effect as your written signature.</div></div></div><div class=\'form-group\'><label for=\'FormField59_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'control-label  \'>Today&#39;s Date:<span class=\'fb-required\'>*</span></label><div><div class=\'clearfix\'><input type=\'text\' name=\'FormField59_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' id=\'FormField59_01eda1b9-1ac0-4433-a0f0-f97630554cc2\' class=\'form-control input-medium isDatePicker\' required data-msg-required=\'This field is required.\' data-format=\'mm/dd/yy\' data-export-label=\'Today_s_Date_\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><p><strong>In order to complete your application, you must submit a paper or electronic copy of the student aid worksheet,* your school&apos;s financial aid award letter, and your official high school or college transcripts to:</strong></p><p style=\'text-align: center;\'><br>Jessica Lassonde, Trust Associate<br>Concord Hospital Trust<br>242 Pleasant Street<br>Concord, NH 03301<br>chtrust@crhc.org<br>(603) 225-2711, ext. 3082</p><p style=\'text-align: center;\'><em>College students who have completed two or more years of higher education need only submit the most recent college transcripts.</em></p><p style=\'text-align: center;\'><em>*To access the student aid worksheet, use the link<br>provided in the sidebar on this page.</em></p><p style=\'text-align: center;\'><em><em>Incomplete applications will not be considered. If the necessary supplemental documents have not been submitted in addition to the online application by the April deadline, the application will be considered incomplete.</em></em></p><div class=\'form-group\'><label  class=\'control-label  \'>Use this checklist to confirm you have:<span class=\'fb-required\'>*</span></label><div><div><fieldset class=\'CheckboxGroup\'><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Completed the online scholarship application\' required data-msg-required=\'This field is required.\' name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_66\' id=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\' class=\'fo-right-margin-5\' data-export-label=\'Use_this_checklist_to_confirm_you_have_\' ><label for=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_1\'>Completed the online scholarship application</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Submitted most recent and/or current official high school and/or college transcripts as applicable\' required data-msg-required=\'This field is required.\' name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_66\' id=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\' class=\'fo-right-margin-5\' data-export-label=\'Use_this_checklist_to_confirm_you_have_\' ><label for=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_2\'>Submitted most recent and/or current official high school and/or college transcripts as applicable</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Submitted a completed student aid worksheet (see sidebar for worksheet link)\' required data-msg-required=\'This field is required.\' name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_66\' id=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\' class=\'fo-right-margin-5\' data-export-label=\'Use_this_checklist_to_confirm_you_have_\' ><label for=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_3\'>Submitted a completed student aid worksheet (see sidebar for worksheet link)</label></div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Submitted financial aid award letter\' required data-msg-required=\'This field is required.\' name=\'79c6a42f-6084-4435-9cf3-aad6e182561b_FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_checkbox_66\' id=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_4\' class=\'fo-right-margin-5\' data-export-label=\'Use_this_checklist_to_confirm_you_have_\' ><label for=\'FormField66_01eda1b9-1ac0-4433-a0f0-f97630554cc2_4\'>Submitted financial aid award letter</label></div></fieldset></div></div></div>\
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<div id=\'form-errors\' class=\'alert alert-danger fade in\' role=\'alert\' style=\'display:none\'></div>\
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