Encompass CNA Scholarship Program Application 2022

Program Details:

Certified Nursing Assistant (CNA) Prep Program Description and Information

CNA classes, labs and clinical rotation.  This short-term program will require intense outside study time.   The last 2 weeks of class will consist of individually scheduled hours of clinical rotation at an outside health care facility.

Personal Information


Secondary and Postsecondary Education

Complete education history.


Child 1 - Stays Home with You or Family Member?
Child 1 - In Public School
Child 1 -Head Start Class?
Child 1 - In Daycare ?

Child 2

Child 2 - Stays Home with You or Family Member?
Child 2 - In Public School
Child 2 -Head Start Class?
Child 2 - In Daycare ?

Child 3

Child 3 - Stays Home with You or Family Member?
Child 3 - In Public School
Child 3 - Head Start Class?
Child 3 - In Daycare ?

Child 4

Child 4 - Stays Home with You or Family Member?
Child 4 - In Public School
Child 4 - Head Start Class?
Child 4 - In Daycare ?

Employment History

If you are awarded a sholarship, do you have transportation?
Have you been laid off over the past 12 months due to no cause of your own?
Employment Status
Do you plan to seek employment in the career field if selected for the program?

Felony/Drug History Conviction(s)

Have you ever been convicted of or pled no contest or guilty to any felony or any serious crime?

List below no more than three reasons why you should be selected.

Would you be comfortable working with the public every day?
Do you have basic computer skills?
Do you have a home computer?
Would you agree to report your employment status for one year?
Would you agree to attend all classes, workshops, study labs and individual career counseling appointments (some appointments may be outside of class times)?
Are you up to date on immunizations?
Are you able to complete a clinical rotation at an outside health care facility?
(Hours will be different than the scheduled class.)
This can be personal, academic, or professional.

Scholarship Application Submission Agreement

By typing your name in the signature box below you agree to the following statement:

I represent and warrant that the information I have given on this application is full and true to the best of my knowledge and belief. I further acknowledge that I understand that I may be asked to provide documented verification of education, experience, and required certifications and/or licensures. And further, I represent and warrant that I have answered fully and truthfully all questions regarding criminal convictions/records. I have read and understand the details of the Encompass CNA Women’s Fund Grant Scholarship Program. I understand that participation in this program may include a criminal background check and drug screen. I understand that I may be required to travel to different locations for class, labs, clinical rotations, workshops, study labs, career counselor appointments or to use the computer lab during times outside of class time. I understand that classes will require extended time and effort outside of class to successfully complete program.
MM slash DD slash YYYY

Student Grade Release Form

I understand that The Women’s Fund of Greater Birmingham is sponsoring this Career Scholarship Program and as such, I am giving permission for Jefferson State Community College to release any information to that organization related to class attendance, conduct, academic honesty and grades. In addition, I am also giving Jefferson State Community College’s One Stop Career Center permission to release information about my participation in any of their services.
MM slash DD slash YYYY

Student Photo Release Form

I , the undersigned, do hereby release all rights or claims in connection with the photo(s) or video in which I appear, for use by Jefferson State Community College or partner grant agencies. I understand that the photo(s) or video, if used, will be used for the promotional purpose of assisting Jefferson State Community College and grant partners and I waive any claim to financial remuneration for the use of these photo(s) or video. I also waive any right to inspect or approve the finished photos and advertising copy. I hereby release Jefferson State Community College, its legal representatives and all persons acting under its permission or authority, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in taking of said picture(s) or video or in any subsequent processing thereof, as well as any publication thereof. I declare that I am of legal age and have every right to contract in my own name in the above regard.
MM slash DD slash YYYY