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Rusteberg Scholarship Application
Requirements: Must be a resident of Monroe or Randolph Counties in Illinois AND intend to work with the elderly.
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* Indicates required question
Email
*
Your email
Date
*
What is TODAY's Date?
MM
/
DD
/
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
*
Your answer
Middle Name
*
If you do not have a middle name, please fill in N/A
Your answer
Last Name
*
Your answer
Maiden or Other
*
What are other names you have legally been known by? If none else, please enter N/A.
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
County
*
Which County do you reside in?
Your answer
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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