THIMA | Careers and Colleges


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THIMA Scholarship Program - Application

Personal
First Name
Last Name
Credential
Are you a member of AHIMA?	Yes AHIMA ID # No
Home Address	Include street, city, state, zip
Address while in school (if different from home address)	Include street, city, state, zip
Home Phone Number
Phone Number while in school
Email
Sex	FemaleMale
Marital Status	Single Married Separated Widowed
Number of Dependents
Will you be employed while attending school?	Yes No
Will you be employed while attending school?	If yes Employer Job Title
List two personal references other than family, clergy, or program director and their mailing addresses	Reference #1: Name Address Include street, city, state, zip Reference #2: Name Address Include street, city, state, zip
Family
Name of parent, guardian, or spouse
Address	Include street, city, state, zip
Phone Number
If you are being supported by a parent, give number of other dependent children
Financial Aid
What is the amount and source of any financial aid that you currently receive?
Education
High School	Include school name, location, date of graduation
Post-High School Education (email transcripts)	Include school name, location, date of graduation
Name of education program	Enrolled or have been accepted
Expected graduation date
Professional or Business Experience
Please describe.
Professional Association Activities
Please describe.
Reason(s) for choosing HIM as a career and an outline of your career goals
Please describe.
Contribution that you can make to the profession
Please describe.
Reason for applying for the scholarship fund
Please describe.

I agree to maintain student membership in AHIMA. Should I not complete the education program, I agree to reimburse THIMA the amount of the scholarship.

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