Page 1. University of Portland/Providence Health & Services Partnership Providence Scholars Program Application

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1 Page 1 University of Portland/Providence Health & Services Partnership Providence Scholars Program Application Questions concerning application completion and technical issues with the electronic application may be directed to Barbara Bodine, bodineb@up.edu or Automatic notifications are sent upon application submission to references and to applicants when references fill out the reference form. Please ensure that applicants and references list the following a safe sender: noreply@q server.com. Some servers think this message is junk. Safe sender instructions. Application deadline for 2019 entry to junior nursing courses: Tuesday, January 15, 2019 by 11:59 pm. All application materials must be received by the deadline to be considered. Save the Date: Providence Scholars Program application candidate interviews, Saturday, March 16, Contact Information * Represents a required field Middle Initial Address* City* State* Zip code* Primary phone number* Secondary phone number Primary address* Secondary address Academics A minimum cumulative GPA of 3.25 and a science cumulative GPA of 3.25 is required to apply. The University will calculate your cumulative GPA from official transcript(s) and will calculate your GPA in completed science courses from Anatomy, Physiology, General Biology, and Microbiology grades. Previous Degree Bachelor's Degree Major Bachelor's Degree Year Graduated Bachelor's Degree Name of University Master's Degree Major Master's Degree Year Graduated Master's Degree Name of University Leadership Experience If you have leadership experience, since high school or within the last five years, list below. Leadership is defined as an officer or board member of a formal group, club, or organization and should include concrete examples of use of 1/6

2 leadership skills. Other examples of how you have exhibited leadership skills are allowed, even when outside a formal leader role. Please include dates, titles or roles, and briefly describe responsibilities and/or examples of when you displayed leadership skills. Dates Title or Role Responsibilities and/or examples of leadership skills Management Experience List any management experience. Management is defined as direct responsibility for the supervision of employees, e.g., hiring, firing, performance evaluations (Examples of positions that are not considered management are: event coordination, office management without direct reports, camp coordinator, etc.). Provide dates of employment, title, employer, number of employees you managed and your supervisory duties. Dates Title Employer # of employees Supervisory Duties Community Service Provide dates (month/year) and briefly describe activities and dates of volunteer experience within the last five years (Maximum: five experiences). Dates (month/year), Service Agency, Activity Approximate Hours of Service Providence Community Service Of the hours listed above, how many of those hours were done with Providence Health & Services. 2/6

3 Work Experience in a Healthcare Setting (do not include volunteer experience) Do you have direct patient care work experience in a clinical setting? If yes, select one of the following roles in the drop down menu. List all of your direct patient care work experience below and indicate which experience/s correspond with your selection from the drop down menu. Dates of employment (month/year) Employment Position Employer Do you have non-clinical work experience in a healthcare setting? Examples: Information Technology, Finance, Housekeeping. If yes, list your employment information below: Dates of employment (month/year) Employment Position Employer Relative is a PH&S Employee If you have a first degree relative who is a PH&S employee, provide the relationship to you: Provide employment information of relative working at Providence: Dates of employment (month/year) Name of Relative Facility/Department Current Status of Applicant I am authorized to work in the United States during my three-year post-graduation commitment at Providence: Please select the category that best describes your status with the University of Portland: 3/6

4 Page 2 References Three references are required for the Providence Scholars Program application. Enter reference information in the fields provided below. It is imperative that the addresses provided are accurate and current. Upon submission of your application, your references will receive an with a link to provide their reference information. You will receive an confirmation when each reference is received by the School of Nursing. References must be submitted by January 31, It is your responsibility to ensure that your references have been submitted by the deadline. * Represents a required field 1. Employer/Supervisor Reference Title* Facility* Address* Phone Number 2. Professor/Instructor Reference Title* School* Address* Phone Number 3. Personal Reference (Non-Family/Non-Employer/Non-Faculty) Affiliation* Address* Phone Number Page 3 Essay In the space provided, please write an essay (500-word maximum) based on the mission statement and core values of Providence Health & Services. Specifically describe how you will incorporate the mission and core values into your work as a potential Providence employee or as a nursing student at the University of Portland. Providence Health & Services Mission/Core Values Mission: As expressions of God's healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable. 4/6

5 Core Values: Compassion Dignity Justice Excellence Integrity To view the complete Core Values, visit the Providence Health & Services Mission & Values page. Write your essay here. Do you speak any language other than English? Specifically, would you be able to conduct a conversation in this language? If yes, explain here (max 100 words): Do you have an advanced knowledge of any culture other than the mainstream American culture? If yes, explain here (max 100 words): Page 4 Additional Considerations Is there anything you think we should consider that is not captured in the previous questions (max 100 words)? Application Submission Submit this application by January 15, 2019 to be considered for the Providence Scholars Program. Applicant Signature Your Providence Scholars Program application and reference forms will become part of your Providence employee file if accepted as a Providence Scholar. Should you be accepted to the Providence Scholars Program, your progress and satisfactory performance throughout the University of Portland School of Nursing program will be closely monitored and reviewed. Continuation of the award will be contingent on a number of basic academic and personal performance criteria. I certify that the information set forth in this application is true and complete to the best of my knowledge. 5/6

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