KHIMA Student Scholarship Application Form

KHIMA Student Scholarship Application Form

Part I: About the Applicant

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
School Address
School Address
City
State/Province
Zip/Postal
Country
Are you an AHIMA Member?
Which scholarship are you applying for?

Part II: Education

Part III: Recommendations

Part IV: Professional or Business Experience

List below the employment you have held starting with the most recent.

Part V: Leadership Activities/Social Consciousness

List and briefly describe organization(s) and your responsibility if an officer,
student representative, committee member, volunteers, etc. Include year(s) of
involvement.

Part VI: Financial Need

Do you anticipate receiving financial aid during the academic year?
Do you have any dependents?

Part VII: Knowledge of Profession and Future Goals

Part VIII: Statement of Authenticity, Repayment if Non-completion, and Signature

I certify that the enclosed information is accurate and authentic. I grant
permission for the health information management program or other program I
am attending to release my current grade point average. If I should be a
recipient of a KHIMA Scholarship Award and fail to complete my education in
the HIA, HIT or other studies, I agree to repay the amount of the scholarship
award within one (1) year of the date I withdraw from the HIM Program