FutureCare NC Certified Nursing Assistant Scholarship Application

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* 1. Applicant Contact Information

Name

Facility

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. In a 400 - 500-word essay, describe/explain why you want to be a Certified Nursing Assistant. What would you like or hope to accomplish during your nursing career.

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* 3. Are you currently accepted into a Certified Nursing Assistant program?

Yes

No

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* 4. If the answer to question #2 is "Yes", what is the name of the program?

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* 5. Have you been employed at a North Carolina Health Care Facilities Association member facility for at least nine months?

Yes

No

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* 6. Do you agree to remain employed at a North Carolina Health Care Facilities Association member facility for at least 12 months after certification?

Yes

No

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* 7. Each scholarship applicant must submit at least three Letters of Recommendation (emailed to erick@nchcfa.org) with 1 of the required letters from the applicants SNF Supervisor. Please share with us the names of who will be submitting your Letters of Recommendation.

SNF Supervisor

Other

Other