PFRNF APPLICATION - MHCH Foundation South Dakota

Name:*

First

Last

Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

E-mail:

Place of Employment:

Employer Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

Employer Contact Name:

First

Last

Employer Phone:

Area Code

-

Phone Number

Employer E-mail:

Place of birth:*

High school:*

Please list any extracurricular activities, school or community organizations you are involved in currently or in the past. Please denote any leadership roles:*

Upon graduation do you plan to reside in a rural area?:*

Yes

No

What percentage of financial aid / student loans will be used to pay for your college?:*

How many dependents do you have living in your household?:*

Please explain any additional financial aid you may be receiving:*

Please explain why you are interested in becoming a nurse (250 words max):*

Describe your interest in rural practice (250 words max):*

Describe your long-term career goals as they relate to rural nursing (250 words max):*

If you are chosen as a Prairie Futures Rural Nurse Fellow, will you be willing and able to contractually agree to complete a 12-month post-graduation residency at Sanford Chamberlain and remain afterwards for two years?:*

Yes

No

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