KHIMA Student Scholarship Application FormKHIMA Student Scholarship Application Form Part I: About the ApplicantName * Name First First Last LastAddress * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone * School Name * School Address * School Address School Address School Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country School Email * Are you an AHIMA Member? * Yes No AHIMA ID Number Which scholarship are you applying for? * Undergraduate Scholarship Graduate ScholarshipPart II: Education High School Name * High School Location (City, State) * Dates of Attendance * Credit Hours or Degree Earned * College #1 Name * College Location (City, State) * Dates of Attendance * Credit Hours or Degree Earned * College #2 Name College Location (City, State) Dates of Attendance Credit Hours or Degree Earned College #3 Name College Location (City, State) Dates of Attendance Credit Hours or Degree Earned College #4 Name College Location (City, State) Dates of Attendance Credit Hours or Degree Earned Health Information Management Program/Graduate Program (to which you have been accepted) * Expected Date of Graduation * Cumulative GPA * Part III: Recommendations Name and positions of persons sending letter of recommendations Part IV: Professional or Business ExperienceList below the employment you have held starting with the most recent. Employer #1 Type of Business Date Position Title/Duties Employer #2 Type of Business Date Position Title/Duties Employer #3 Type of Business Date Position Title/Duties Employer #4 Type of Business Date Position Title/Duties Part V: Leadership Activities/Social ConsciousnessList and briefly describe organization(s) and your responsibility if an officer, student representative, committee member, volunteers, etc. Include year(s) of involvement. Professional or school-related organization. * Other organizations - community, civic, church, personal interest. * Other recognized leadership activities (e.g., professional presentation, professional publication, awards booklet. State the year and nature of honor/award. * Part VI: Financial NeedDo you anticipate receiving financial aid during the academic year? * Yes No If you anticipate receiving financial aid during the academic year, list the source and amount. Do you have any dependents? * Yes No If yes, list their relationship to you Describe any special financial circumstances that warrant consideration for this award. * Part VII: Knowledge of Profession and Future Goals How did you become acquainted with the health information management (HIM) profession? * Why did you choose the health information management profession and what are your career goals? * What strengths do you possess that will assist you to become a qualified health information management professional? * 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 Signature * signature keyboard Clear Signature of * Date * If you are human, leave this field blank. Submit
