I am employed by a LeadingAge Ohio member in good standing and am applying for the following scholarship:
Clark R. Law Executive Management Scholarship
For up to $2,500 for an individual enrolled in an administrator-in-training program leading to core executive management knowledge, or in a program furthering executive management skills
Aging Services General Scholarship
For up to $1,500 for an individual desiring to advance their careers in aging services fields, including nursing (i.e., those wishing to move from STNA to LPN, or LPN to RN, etc.); and, dietary, activities, maintenance, therapy and other professional lines
If you need assistance completing this form please contact:
STEP 1: Applicant & Applicant's Employer Information:
First Name Last Name Title LeadingAge Ohio Member Organization Work Address City State Zip Work Email Work Phone
Home Address City State Zip Home Email Home Phone
Supervisor's Name Supervisor's Title Supervisor's Email
Applicants must have been hired prior to July 1, 2018 to be eligible for consideration.
Date of Hire by this organization ?
Have you been continuously employed by this organization since this date? choose one Yes No If not, please explain:
STEP 2: Description of Educational Program (limit 250 words):
Please describe the educational program in which you are participating or wish to participate, including name of school, description of the educational program and the name of the school/contact person. (Limit 250 Words)
Enrollment date in coursework: ?
Date range of coursework:
STEP 3: Goal of Educational Program (limit 500 words):
Please describe, in the provided space below limited to 500 words, your current job responsibilities and career objectives, including how this coursework will benefit you and your organization. Include any special recognition/awards earned; other educational efforts completed; and any additional information to help distinguish the merits of your application.
STEP 4: Community Involvement/Diversity (limit 250 words):
Please describe, in the provided space below limited to 250 words, 1) how you personally demonstrate commitment to those you serve (Include volunteer activities, service to the greater community or other outside organizations such as participation in Rotary, public education on senior issues, etc.) and 2) how does your life reflect cultural, ethnic, racial or economic diversity?
STEP 5: Financial Information:
Total Amount Requested: Total anticipated expenses
Note: if you are applying for assistance for a course of study that will be completed over several quarters or semesters, please note the anticipated expenses over the entire period
Does your employer offer financial assistance?
choose one Yes No If yes, you must provide a copy of your organization's financial assistance policy.
Do you have any personal financial limitations that would be helpful in evaluating your request for this scholarship?
choose one Yes No If yes, please explain:
Have you discussed support for your educational endeavors with your employer and/or local businesses? (LeadingAge Ohio scholarships may be awarded as a supplement to other scholarships up to the full cost of tuition)
choose one Yes No
Are you a recipient of a LeadingAge Ohio Foundation scholarship within the past three years?
choose one Yes No
If so, please indicate the year(s) scholarships were received and amount of each scholarship received separated by commas in the space provided (i.e. 2010 $600, 2011 $400, 2012 $500):
STEP 6: Letter of Recommendation:
By checking here I acknowledge that I must submit a SIGNED letter of recommendation from an immediate supervisor or department head which also includes signature of President/CEO or Executive Director. This should highlight achievements, personal and professional growth during employment and how the educational program will benefit the applicant and organization. Instructions for submitting this letter will be included in your email confirmation.