THIMA Scholarship Application Demographic InformationName * Name Name Name Credential(s) Address Address Address Address Address Address StateAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address Email * Phone Are you a member of AHIMA? Yes No AHIMA ID # Gender Male FemaleMarital Status Single Married Separated WidowedWill you be employed while attending school? Yes NoIf you are employed, please list your employer and job title. Title Company Name Upload two personal online letters of reference (other than family, clergy, or program director). Candidates are encouraged to obtain one of the two personal letters from a clinical instructor. Reference Letter #1 * Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Reference Letter #2 * Drop a file here or click to upload Choose FileMaximum file size: 268.44MBFamilyName of parent, guardian, or spouse Name of parent, guardian, or spouse Name of parent, guardian, or spouse Name of parent, guardian, or spouse Address Address Address Address Address Address StateAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address Phone 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 (Include school name, location, date of graduation) Name of education program (Enrolled or have been accepted) Expected graduation date Upload transcript * Drop a file here or click to upload Choose FileMaximum file size: 268.44MBProfessional or Business Experience Please describe your professional or business experience Professional Association Activities Please describe professional association activities Reason(s) for choosing HIM as a career and an outline of your career goals Please describe your reason(s) for choosing HIM as a career and an outline of your career goals Contribution that you can make to the profession Please describe contribution that you can make to the profession. Reason for applying for the scholarship fund Please describe your reason for applying for the scholarship fund. I agree to maintain student membership in AHIMA. * AgreeShould I not complete the education program, I agree to reimburse THIMA the amount of the scholarship. * I agree If you are human, leave this field blank. SubmitΔ
