2022 Auxiliary Scholarship Application 
          
          
         SECTION 1 
          
         Full Name                                                                                                                         
          
         Address                                                               City, State & Zip                                           
          
         Date of birth                                        Phone                            Cell phone                                  
          
         Email:                                                                        
          
         Do you work at Advocate Aurora Health? Yes                   No               Site/department:                                    
          
         Do you or your family members currently volunteer or have volunteered at Advocate Aurora Health? Yes                    No        
          
         If yes, what facility:                                                                                                            
          
         Education completed to date:                                         Dates attended:                    Degree received: 
          
         High School                                                                                                                        
          
         College                                                                                                                           
                   
         Other                                                                                                                             
          
         Institution you will be attending                                                                                                 
          
         Institution address:                                                                                                              
                                                      
         Course of study*                                                                                                                  
         *Please enclose verification of acceptance in a Health Care Professional Program.                                                               
          
         Length of program                                                    Full time Yes ____ No____ Part time Yes ____ No ____ 
                                    
         Name of degree expected                                               Year of graduation                                          
          
         SECTION II 
          
         Dependents (age & relationship)                                                                                                   
          
         Number of children in school                                                   How many in college                                
          
         Spouse’s name & occupation                                                                                                           
                              
         SECTION III  
          
         Father’s or Guardian’s occupation                                                                                                 
          
         Mother’s or Guardian’s occupation                                                                                                 
          
         Siblings (number & ages)                                                                                                          
          
         Siblings in school                                                   Siblings in college                                          
         Advocate Good Shepherd Hospital 2022 Auxiliary Scholarship Application                               Page 1 of 4 
                                                                                                                                           
        Name 
        SECTION IV 
        FINANCIAL INFORMATION 
        List your resources and anticipated expenses for the coming school year in the columns below: 
                  Anticipated income & assistance                       Expenses (per academic year) 
         Parents                   $                         Tuition & fees             $ 
         Personal Savings          $                         Room & Board               $ 
         Employment                $                         Books & Supplies           $ 
         Loans                     $                         Transportation             $ 
         Grants, etc.              $                         Personal & Other           $ 
         Total                     $                         Total                      $ 
        List any extenuating financial circumstances you feel are relevant: 
        List scholarships, grants, or tuition reimbursements applied for and amounts granted for next school year: 
        1                                    $                      2                                    $ 
        3                                    $                      4                                    $ 
        List scholarships, grants, or tuition reimbursements currently being applied for next school year but awaiting responses: 
        1                                    $                      2                                    $ 
        3                                    $                      4                                    $ 
        Advocate Good Shepherd Hospital 2022 Auxiliary Scholarship Application                  Page 2 of 4 
        Name 
        SECTION V      
        List employment beginning with the most recent: 
        Employer’s name and address                 Position                      Dates of employment 
        List professional societies or activities, including offices held or honors received: 
        List additional information pertinent to your interest, goals, experience and/or training: 
        List any additional information you feel should be considered by the Scholarship Committee: 
        SECTION VI 
        Supporting documentation: 
            1. Submit three (3) current (dated within the last nine [9] months) letters of recommendation.
                   a.  If you are a student, at least two of the three letters must be current (dated within the last nine [9]
                       months) academic references.
                   b.  If you are not currently enrolled in an academic program, the three current (dated within the last nine
                       [9] months) letters may be from employers, clergy, or friends.
            2. Essay - describe in your own words why you want to become a Health Care Professional. The essay is to be
               limited to a one-page, double-spaced typed sheet; font size 12; font style Times New Roman.
            3. Letter of acceptance - Submit a letter of acceptance from the institution you will be attending – stating your
               acceptance into a Health Care Professional Program
            4. Official transcript - Submit your Official Transcript of your most recent grades.
        Advocate Good Shepherd Hospital 2022 Auxiliary Scholarship Application                 Page 3 of 4 
            
            
            Name                                                                       
            
           SECTION VII 
            
           Endorsement and Consent for Release of Information 
           I declare that I have completed this application and to the best of my knowledge the information given is complete and 
           correct.  I hereby consent to the release of any information in connection with the foregoing that in the sole judgment of the 
           Auxiliary of Good Shepherd Hospital may be of assistance in evaluating my scholarship application.  I hereby waive any 
           confidentiality with respect to such information insofar as the Auxiliary of Good Shepherd Hospital is concerned, since it 
           is my understanding that the information will be used solely for the evaluation of my application for scholarship and for no 
           other purpose. 
            
           I understand, that to be eligible to the scholarship, I must: 
                -     reside in the hospital service area which includes zip codes 60010, 60012, 60013, 60014, 60021, 60042, 60047, 
                      60050, 60051, 60060, 60067, 60073, 60084, 60098, 60102, 60110, 60156 
                -     I must be accepted into one of the following fields of study: Nursing, Physician, Physician Assistant, Physical 
                      Therapy, Occupational Therapy, Speech and Language Pathology, Radiology, Pharmacy, Social Work 
                                       
                                       
           _______________________________________________                                                                                                       
           Signature (Full first and last name)                                                                                 Date 
            
                                                                                                                                          th
           This application and all required documentation MUST be emailed no later than April 15 , 2022 4pm to 
           GSHP-VolunteerAuxiliary@aah.org  
            
                                                                                       th
           Incomplete or applications received after April 15 , 2022 will NOT be reviewed for scholarship 
           consideration. 
            
           Application checklist: 
                     Completed application. 
                     Your essay as to why you want to become a Health Care Professional. 
                     Three current letters of recommendation.  
                     Letter of acceptance  
                     Official transcript of your most recent grades. 
                 
           All finalists will be notified of their interview date in early May 2022. Interviews will be held later in May at 
           Advocate Good Shepherd Hospital or via Zoom. 
            
           Any questions, send us an email at GSHP-VolunteerAuxiliary@aah.org 
            
           Advocate Good Shepherd Hospital 2022 Auxiliary Scholarship Application                                                       Page 4 of 4