Jackie Liesemeyer Scholarship Application

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Please list the best phone number to contact you.

Are you currently employed?(Required)

Yes

Place of Employment:(Required)

Employers Address:(Required)

Street Address Address Line 2 City State ZIP Code

Employers Phone(Required)

Current Title(Required)

Person who will always know how to contact you:

Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Please share the number of the person who will always know how to contact you.

MPHA Involvement

Are you a current MPHA member?(Required)

Yes

If yes, how long have you been a member?(Required)

Describe your involvement or participation in MPHA. Include all MPHA committees and offices you have served.(Required)

Academic Background

College/University/ Other Program(Required)

Years Enrolled

Degree/Certification Received(Required)

Current Public Health Academic Training

Program Where Currently Enrolled:

Address

Street Address Address Line 2 City State ZIP Code

Degree Goal

Number of hours completed toward degree:

Copy of official transcript required if applying for college/university class must be uploaded here.:

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 5 MB.

Current Public Health Academic Training

(Include the following information for each work experience.)

Employer 1

Dates of Employment 1

Position at Employment 1

Brief Description of Responsibilities at Employment 1

Employer 2

Dates of Employment 2

Position at Employment 2

Brief Description of Responsibilities at Employment 2

Employer 3

Dates of Employment 3

Position at Employment 3

Brief Description of Responsibilities at Employment 3

Volunteer/Community Involvement

(Include the following information for each organization.)

Organization 1

Dates of Service @ Organization 1

Brief Description of Responsibilities at Organization 1

Organization 2

Dates of Service @ Organization 2

Brief Description of Responsibilities at Organization 2

Organization 3

Dates of Service @ Organization 3

Brief Description of Responsibilities at Organization 3

Other Pertinent Information

Describe your most gratifying and successful accomplishments (personal and professional).(Required)

Explain how the scholarship would help you further your public health career.(Required)

Explain your commitment to public health in Missouri now and your plans after completing your public health related education.(Required)

List the event, location, date and estimated costs of your request:

For continued education meetings, seminars, conferences, etc., describe specifically how the event will benefit your professional development and enhance your contribution to the public health field:

Describe your need for financial assistance from this scholarship (i.e. loss of financial support from your employer for education activities, limited personal resources for professional education, etc.) Include a description of other financial resources to be used in achieving your continuing education plan or degree:

Official transcript(s) of grades if planning to use scholarship for college/university work must be uploaded here.:

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 5 MB.

Copy of Confirmation of enrollment as a graduate or undergraduate student if planning to use scholarship toward degree work. must be uploaded here.:

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 5 MB.

Copy of Description of educational meeting, seminar, continuing education, specific certification, test or course work and how it falls within guidelines of MICH or NPHAB accreditation. Budget of expenses must be uploaded here.:

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 5 MB.

Copy of final report of how grant facilitated accreditation goals, status of accreditation process and total expense accounting to MPHA Education Foundation Board within two weeks of next annual meeting must be uploaded here.:

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 5 MB.

Missouri Public Health Association