Student Scholarship Application

Applicant Information

First
Last
mm/dd/yy
Primary Phone
Alternative Phone (optional)
Current Address/Residence
Primary Email

Employment Information

Family Information

First
Last
Current Address/Residence

References

List two personal references (other than family, clergy) and provide their addresses.
First, Last
Street, City, State, ZIP Code
Primary Phone
First, Last
Street, City, State, ZIP Code
Primary Phone
Maximum upload size: 134.22MB
Maximum upload size: 134.22MB

Education Information

Name, Location, Date of Graduation
Post-High School Education - Attach Transcript (PDF Files Only) *
Maximum upload size: 2MB
Write a brief summary of your professional/business experience.
Please list or describe any professional association activities you are apart of.
Please attach applicant letter explaining KHIMA Scholarship Guidelines item #2 line e. (PDF Files only) *
Maximum upload size: 134.22MB
Please attach proof of AHIMA membership, if applicable. (PDF Files only)
Maximum upload size: 134.22MB

Signatures

I agree to maintain student membership in AHIMA. Should I not complete the education program, I agree to reimburse KHIMA the amount of the scholarship. By clicking the `Submit` button below, I hereby certify that all the information I have given is accurate to the best of my knowledge.
First and Last
  • Applications must be submitted to Awards and Scholarships Chairman of KHIMA by September 25, 2020. To be eligible for the scholarship, candidates must be student members of AHIMA and designate Kentucky as their component state association (CSA) and must attend an accredited HIA/HIT program.
  • Scholarship recipients must serve on a KHIMA committee for a period of one year.