GREAT Application

Scholarship (training) applying for:*

Personal Information

Name*

First Last

Sex

Age

Date of Birth*

Race

Address

Street Address City State ZIP Code

Cell Phone*

Phone (alternate)

Email*

Do you have a valid Driver's License?*

Yes
No

Employment History

Begin with most current employment and provide up to 3 years of employment if possible.

Employment One

Name of Employer

First Last

Position

Phone

Supervisor's Name

Employment Date From:

(MM/YY)

Employment Date To:

(MM/YY)

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, promotions or certifications gained while you worked at this company:

Employment Two

Name of Employer

First Last

Position

Phone

Supervisor's Name

Employment Date From:

(MM/YY)

Employment Date To:

(MM/YY)

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, promotions or certifications gained while you worked at this company:

Employment Three

Name of Employer

First Last

Position

Phone

Supervisor's Name

Employment Date From:

(MM/YY)

Employment Date To:

(MM/YY)

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements, promotions or certifications gained while you worked at this company:

Education

High School/GED

Name

Location

Dates Attended From:

(MM/YY)

Dates Attended To:

(MM/YY)

Did you graduate?

Yes
No

Diploma/Certificate

Other Information

Have you ever been convicted of a felony?

Yes
No

Have you ever participated in any other Delta Health Alliance/Deer Creek Promise Community programs?

Yes
No

If yes, please list:

References:

Please provide 3 references that can be contacted. Only one reference may be a relative.

Reference One:

Name

First Last

Relationship

Organization (if applicable)

Address

Street Address City State ZIP Code

Cell Phone

Phone (alternate)

Email

Reference Two:

Name

First Last

Relationship

Organization (if applicable)

Address

Street Address City State ZIP Code

Cell Phone

Phone (alternate)

Email

Reference Three:

Name

First Last

Relationship

Organization (if applicable)

Address

Street Address City State ZIP Code

Cell Phone

Phone (alternate)

Email

How did you hear about the GREAT program? Please check one.

Newspaper
Social Media
Delta Health Alliance employee
Other

Please Provide

GREAT Scholarship

Two of DCPC’S goals are to ensure students graduate from high school and to obtain a post-secondary degree. In the space below, please tell us how this scholarship will help you as an individual and how you will use your certification to make a difference in your community.

Your story:

Signature

By signing and dating this application, you verify that the information that you have provided is factual to the best of your knowledge.

“Delta Health Alliance will not discriminate against any applicant on the basis of race, color, religion, sex, sexual orientation, national origin, disability, age, or disabled veteran or veteran of the Vietnam Era.”

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Personal Information

Employment History

Employment One

Employment Two

Employment Three

Education

Other Information

References:

Reference One:

Reference Two:

Reference Three:

GREAT Scholarship

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