Rusteberg Scholarship Application

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Requirements: Must be a resident of Monroe or Randolph Counties in Illinois AND intend to work with the elderly.

Email *

Date *

What is TODAY's Date?

YYYY

Program *

Indicate the type of program in which you will be/are enrolled in at Beck:

Practical Nursing Program (obtain a copy of your FAFSA Report)

Certified Nurse Assistant Program

Cohort *

Which cohort are you applying for?

January

July

Certified Nurse Assistant

First Name *

Middle Name *

If you do not have a middle name, please fill in N/A

Last Name *

Maiden or Other *

What are other names you have legally been known by? If none else, please enter N/A.

Street Address *

City *

Zip Code *

County *

Which County do you reside in?

Duration *

How long have you lived at this address?

Less than 1 year

1-2 years

2-3 years

3+ years

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