MOPHA - Missouri Public Health Association
Missouri Public Health Association
722 E. Capitol Avenue
Jefferson City, MO 65101
573-634-7977
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Name
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Address
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Place of Employment:
Employers Address
Employers State
Current Title
Home Phone
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City
Zip
Work Phone
Work City
Work Zip
Person who will always know how to contact you:
Name
Address
State
Work Phone
*
Work City
Work Zip
MPHA INVOLEMENT
Are you a current MPHA member?
Yes
No
If yes, how long have you been a member?
Describe your involvement or participation in MPHA. Include all MPHA committees and offices you have served.
ACADEMIC BACKGROUND
College/University/
Other Program
Years
Enrolled
Degree/Certification
Received
Program Where Currently Enrolled:
CURRENT PUBLIC HEALTH ACADEMIC TRAINING
Address
City
State
Zip
Degree Goal:
Number of hours completed towards goal:
Copy of official transcript required if applying for college/university class:
PUBLIC HEALTH EXPERIENCE
(Include the following information for each work experience.)
Employer:
Dates of Employment:1
Position:
Brief Description of Responsibilities:
Employer:
Dates of Employment:2
Position:
Brief Description of Responsibilities:
Employer:
Dates of Employment:3
Position:
Brief Description of Responsibilities:
VOLUNTEER/COMMUNITY INVOLVEMENT
(Include the following information for each organization.)
Organization:
Dates of Service:
Brief Description of Responsibilities:
Organization:
Dates of Service:
Brief Description of Responsibilities:
Organization:
Dates of Service:
Brief Description of Responsibilities:
Describe your most gratifying and successful accomplishments (personal and professional).
Explain how the scholarship would help you further your public health career.
Explain your commitment to public health in Missouri now and your plans after completing your public health related degree.
COMPLETE ONLY FOR THE LIESEMEYER SCHOLARSHIP APPLICATION
(Include the following information for each organization.)
I. Explain briefly why you are working in the field of public health nursing and your plans for the future.
COMPLETE ONLY FOR THE WEINEL SCHOLARSHIP APPLICATION
(Include the following information for each organization.)
I. For continued education meetings, seminars, conferences, etc., describe specifically how the conference, meeting or seminar will benefit your professional development and enhance your contribution to the public health field.
II Please list the estimated costs of your request.
III Please describe your need for financial assistance from this scholarship (i.e. loss of financial support from your employer for education activities, limited personal resources for professional education, etc.) Include a description of other financial resources to be used in achieving your continued education plan or degree.
Missouri Public Health Foundation Personal Reference Form
To enrich her/his career in the public health field, the individual named below is applying for the scholarship(s) checked below:
Missouri Public Health Association Professional Scholarship
Jackie Liesemeyer Nursing Scholarship
Edna Dell Weinel Public Health Scholarship
This reference form must be included for the individuals application to be evaluated.
Applicant Name:
Address:
State:
Phone:
City:
Zip:
1. How long have you known the applicant?
2. How long have your supervised the applicant's work in public health?
3. In your opinion, what commitment and special attributes does this applicant have to enrich public health in Missouri?
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