Society for Health Systems (SHS) Scholarship Nomination Form

To nominate a student for the SHS scholarship , complete this form as indicated. This scholarship is awarded to one person each year. Please forward any questions to Bonnie Cameron, headquarters operations administrator, 770-449-0461, ext. 105.

Nominations must be received by Dec. 1.

Nominee Information:

Nominee's Name:






E-mail Address:


Mailing Address:


City, State, Zip code


Nominee's Phone Number:


Nominee's Fax Number:


Nominee's Membership Number:


Nominee's Chapter Number:

Does nominee have a minimum GPA of 3.00 on a scale of 4.00?

Nominator Information:


Nominator's Name:

Nominator's Title:

Nominator's School:

Nominator's Mailing Address:

Nominator's City, State,  Zip:


Nominators Phone Number:


Nominator's Fax Number:


Nominator's E-mail Address:

List names and addresses of three individual that have consented to provide professional or academic references for the nominee. Each individual must submit a letter of reference via e-mail to by Dec. 1.

Reference 1 name and address:


Reference 2 name and address:


Reference 3 name and address:



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