Hendricks Healthcare Sector Partnership Grant ApplicationFall 2022If you are currently pursuing a certificate or degree in a healthcare field or are interested in getting started in one, COMPLETE this application. We might be able to help!Applicant Information* indicates a required fieldName* First M.I Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Phone*Email* DOB* Month Day Year Gender* Male Female Ethnicity Hispanic or Latino Not Hispanic or Latino Race American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian White Black or African American Level of Education Obtained Some High School High School Diploma or Equivalent Some Post Secondary Education Post Secondary Certification Associates Degree Bachelors Degree Masters Degree Doctorate Degree Employment InformationAre you currently employed?* Yes No Current Employer* Start Date* Month Day Year Current Position* Wage* Education/Training InformationWhat is your declared major/course of study?* What courses are you taking during the Fall 2022 semester?* What College/University are you attending?* Student ID #* Program/Course Start Date MM slash DD slash YYYY Expected Graduation Date* MM slash DD slash YYYY Why are you interested in the healthcare field?*Tell us about your goals in the healthcare field.*Have you been affected by COVID-19? If so, how? Did it have an influence on your decision to pursue a career in healthcare?*Did someone recommend you apply to this grant?* Yes No Name of person who recommended you to this grant.* Company name of person who recommend you to this grant.* Phone number for person who recommended you to this grant.* E-mail address for person who recommended you to this grant.*
