Congo Helping Hands

Name   _____________________________________  Today’s Date  ________________

Date of Birth_________________________________  Sex (male/female) ____________

Residence (village) _______________________________________________________

Marital Status (single/married/widowed/divorced)  ______________________________

How many members are in your immediate family including yourself and spouse? ________

List the names and ages of your children, if any  __________________________________

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 Describe previous education:  _______________________________________________

 ________________________________________________________________________

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 Which school of nursing do you wish to attend? _________________________________

 Why do you want to study nursing? __________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

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Why do you need financial assistance?  Please describe in detail: _________________  

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

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List three persons who can validate your need for financial assistance:  ______________

 ________________________________________________________________________

 ________________________________________________________________________

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  What are your intentions after obtaining a nursing degree?_________________________

 ________________________________________________________________________

 ________________________________________________________________________

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Please attach a letter of recommendation from an instructor or medical professional.

Who completed this form if other than the applicant? 

 _______________________________________________________________

(printed name, signature and date)

Applicant for nursing financial aid scholarship:  

 _______________________________________________________________

(signature and date)