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Scholarship Application

SCHOLARSHIP

APPLICATION

“It is with Passion  that our greatest work is achieved.”

The Scholarship’s Pay It Forward Program


A passionate and forward thinker,  mentor who loved her students, Estelle R. Ford had a love for helping  and encouraging vision to help raise up the next generation  others to embrace their dreams and reach for excellence in their chosen field of nursing. . Through countless acts of kindness, tremendous faith, a positive attitude in life,  and an endless devotion to her students, , Estelle changed the lives of those she touched.  

Due to her passion for nursing, she created and sponsored the Future Nurses Club at Gardner High. and took a personal interest in  young women who joined and later became nurses, many having graduated from the Henry Heywood School of Nursing.


The Scholarship's Pay it Forward Program was also created in 2016 to further Estelle's vision to help raise up the next generation of leaders to help make a difference in their school or community through a leadership service project.


Operated by a non-profit foundation,  Estelle R Ford Future Nurses Scholarship is completely dependent on donations. Scholarships are to be awarded annually to qualified applicants who are either from the Garner area or who plan to serve  the  GreaterGardner Community upon graduation. Candidates selected will  demonstrate excellence in scholarship, character, leadership, and service.


2017 Community Foundation of North Central Massachusetts.

649 John Fitch Highway

Fitchburg, MA 01420

978-345-1459

[email protected]


Name of Student:_____________________________________________________________________

Yr. in school:___________________________________________________________________________

Address: _______________________________________________________________________________

City: ___________________________________________________________________________________

State: __________________________________________________________________________________

 Zip: ____________________________________________________________________________________

Phone Number: _______________________________________________________________________

Email: __________________________________________________________________________________

Current GPA: (Preference will be given to students with a GPA of 3.0 and above.) ___________


• Your interest in applying for this scholarship is appreciated. Please note that you must be a second year student in a two year nursing program or a third or fourth year nursing student in a four year program in order to apply. Additional criteria for this scholarship is that you are either from Gardner, MA or a surrounding community or attending a two or four year nursing program in one of the colleges surrounding Gardner. The applicant must be willing to serve the community in a nursing capacity for at least one year after graduation, in a medical facility within the vicinity of Gardner or the surrounding area. All candidates to be considered must complete this application form and participate in an “in person” or telephonic interview with members of the scholarship committee.

• The Estelle R. Ford Future Nurses Scholarship exists to encourage excellence in nursing, character, leadership and community service.

• Several $500 scholarships will be awarded to qualified applicants who have completed a service project that conforms to the requirements of the "Pay It Forward" Project (see attached Pay It Forward document) associated with this scholarship. Awarded scholarships will be applied to the scholarship recipients' tuition during their senior year of college.

Please provide the following information:

1. Describe, in one page, all extracurricular and/or community service activities you have been involved in (e.g., community service, sports, clubs, student government, recognized charities, clubs, or organizations).

2. Write a one page essay detailing your internship and practicum experiences in the nursing field. What are you doing in your life that reflects your passion for nursing and care of others.

3. Attach a letter of recommendation from a college professor, or a representative from the medical community or other health or community service organization who support your application for this scholarship.

4. Please fill out the attached Pay It Forward Photo and Name Release Form and submit it with this application.

5. If you have any questions about the application process, please contact Ms. Marjorie Fischer or Mr. John Ford, Scholarship Committee Chairs and send via email to: [email protected] or [email protected]

NOTE: Please type essays in 12 pt. Times New Roman font. Once accepted, you will be contacted to set up an interview with the Scholarship Board. Incomplete applications will not be considered.


Scholarship candidates are required to complete a Pay It Forward (PIF) Leadership Service Project prior to receiving their scholarship. This service project emphasizes the value of service and leadership within the community, as well as developing compassion for others and other important skills.

Projects that benefit the community can included hosting an informational workshop for high school students interested in a nursing career, volunteering at and/or assisting with activities at a local retirement or nursing home, volunteering at a shelter or food pantry for the needy, or providing clothing and supplies to shelters for homeless Veterans in and around the Gardner community.

(While it is acceptable to involve others, it is important for the applicant to demonstrate their leadership skills in this project.)

If selected, you will be paired with an advisor who will assist with developing a qualifying service project. The initial training meeting with your mentor will be announced after the candidates are selected.

Please describe the primary skills and tasks you think will be needed to complete a community service project:

__________________________________________________________________________________________

Please send completed application to: The Estelle R. Ford Future Nurses Scholarship, Attn:

Ms. Marjorie J. Fischer and/or Mr. John R. Ford, Chairs; c/o Community Foundation of North Central Massachusetts, 649 John Fitch Hwy., Fitchburg, MA 01420 or Email: [email protected]


Photo Release Form

2017-2018

-Permission to Use Student’s Photograph

The Estelle R. Ford Future Nurses Scholarship and Pay It Forward Program may wish to use photographs of the student recipients in various forms of publicity. Any such photographs would highlight the student(s) either demonstrating learning techniques or participating in community program activities as they relate to the Estelle R. Ford Future Nurses Scholarship Program.

Only with the permission of the recipient will an individual’s name be released with any photographs.

Student’s Name: _______________________________________________________________________

____ I consent to the use of my photograph image (print, online, video, etc.).

____ I DO NOT consent to the use of my photograph image.

____ I consent to the use of my name with the release of any photographs.

____ I DO NOT consent to the use of my name with my photograph image.

Recipient’s signature _______________________________________ Date _________________

Email address __________________________________________________________________________

Phone number _________________________________________________________________________


Click Here to Add a Title

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