Skip survey header

KHIMA Student Scholarship Education Enrollment Verification

Instructions to Applicant: After filling in your name in the appropriate blank, forward this form to the director of the health information management program in which you have been accepted.

Instructions to Program Director: The student named below has applied for a scholarship through the Kansas Health Information Management Association. In order to review the application, we must verify this student's acceptance in an accredited health information management program or approved graduate program. If this student has been accepted in the final year of your program, please complete and sign this form. 
Student's Name
Cumulative GPA
4. Signature of Program Director/Department Chairman *This question is required.
Signature of
This question requires a valid date format of MM/DD/YYYY.