The Kelly Family Nursing Scholarship Awards

A member of the Philanthropy team will reach out once this form is completed. If you have any questions, please email HHPhilanthropy@hhchealth.org.

Name(Required)

First Last

Are you still employed by HHC?(Required)

Yes

I am leaving the organization

Hartford HealthCare Employee ID Number(Required)

Which Hartford HealthCare hospital/entity are you employed by?(Required)

Phone Number(Required)

Email(Required)

Educational Institution(Required)

Educational Institution Address(Required)

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

Have you completed your education since applying?(Required)

Yes

Dropped out of the program

If no, please state your anticipated program completion date.

Have you completed all payments to your educational institution?(Required)

Yes

Additional Comments