Education Assistance

Education Assistance Inquiry

Please complete this intake form if you are interested in applying for a Foundation Education Grant or Scholarship offered by one of Memorial Health System's four affiliate hospital foundations:

  • Abraham Lincoln Memorial Hospital Foundation
  • Memorial Medical Center Foundation
  • Passavant Area Hospital Foundation
  • Taylorville Memorial Hospital Foundation

Following the completion of this intake form, you will be notified by Memorial's Organization Development Department with additional information to complete the application process for a foundation education assistance opportunity.


Applicant Information

First Name
Middle Name
Last Name
Email
Address
City
State
Zip
Employee ID (if applicable)
Phone
College Address (if applicable)
Program of Study
Are you currently employed by Memorial Health System?
If no, do you have an immediate family member who works at Memorial Health System?
Name of Professional Reference:
E-mail of Professional Reference
Name of Academic Reference
E-mail of Academic Reference