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New Jersey Chapter - Society For Public Health Education
Scholarship/Professional Development Awards Application
(Check One) Scholarship ___ Anna Skiff Award ___ Professional Development Award ___
1. Personal Data
Name ________________________________
Address_________________________ City_______________
State____________ Zip______
Social Security Number______________ ___ Male __ Female
Are you a current, dues paying member of NJ SOPHE
as of the date of this application? ___ Yes ___ No
Permanent Address ___________________________________________
Street Bldg./Apt.#
___________________________________________
City State Zip Code
__________________________________________
County of Residence ____________
Mailing Address (if other than above)
Street Bldg./Apt.#
__________________________________________
City State Zip Code
________________________________________
Home Phone ( )_____________ Work Phone ( )_____________ /email______________
2. Academic Information
Are you currently pursuing an academic degree in health education?
__Yes __No
If No, Are you pursuing a degree in a related field? __Yes __No
If Yes, Please specify _______________________________
Have you recently graduated from an Academic Program? (Health Education or related
field)
___ Yes ___ No
- If Yes, Mo./Yr. ________
Baccalaureate___________ Masters____________Doctorate_________________
Full Time__________________ Part-Time__________ # of credits/semester__________
College/University_____________________ State_____________
What is your overall GPA___________________
3. Professional History
Work Related: Please list all relevant professional work experience with the most recent first:
Employer - Address - Position/Title Dates
Non-Work Related:
Have you been involved in health education activities and/or projects (outside of work) over the past three
years?
yes ______ no _______
If yes, please list specific activity and time frame.
4. Personal Statement:
Please provide a one to two page personal statement/self-assessment. Briefly state your professional goals and describe key learning's and growth based on your work, academic and voluntary health education experiences. Your personal statement must specifically focus on goals and interests related to the award for which you are applying.
5. References
Please provide three letters of reference from individuals familiar with your professional skills and abilities. One letter must be from a current member of NJ
SOPHE, one from a professor/academic advisor (if you are applying for the scholarship) and the other (s) from a professional supervisor, co-worker, or community member who has worked with you on a health education project/activity. Please list your three references and attach their letters to this application. Letters can be sent separately but no allowances will be made for late or non-receipt.
Name _____________________________ Title
_______________
Address ________________________________________________
Phone ( ) __________________
Name _____________________________ Title
_______________
Address ________________________________________________
Phone ( ) __________________
Name
_____________________________ Title _______________
Address ________________________________________________
Phone ( ) __________________
Mail this application and all supporting materials, by Friday, October 10, 2003 to:
Jennifer Kidd
NJSOPHE
P.O. Box 384
Burlington, NJ 08016
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