Form IHS-817 Scholarship Program Agreement

HEALTH PROFESSIONS PREPARATORY AND PREGRADUATE

u.s. DEPARTMENT OF HEALTH AND HUMAN SERVICES

EDUCATION SCHOLARSHIP PROGRAM AGREEMENT

PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

SCHOOL YEAR 2009 - 2010

Section 103 of the Indian Health Care Amendments of 1988 authorizes the Secretary of Health and Human Services
("Secretary"), acting through the Indian Health Service, to provide applicants selected to be participants in the Health
Professions Preparatory and Pregraduate Education Scholarship Program for Indians ("Scholarship Program") with scholarship
awards. The statute is codified at 25 U.S.c. 1613 and the implementing regulations are codified at 42 CFR, Part 36, Subpart J,
Subdivision J-3. In return for awards, applicants must indicate an intent to serve Indians as health care professionals in the
discipline or specialty for which the award is given upon completion of their health care professional education.
Program policy requires applicants to submit with their applications a signed Agreement which states the terms and
conditions of participation in the Scholarship Program. The Secretary shall sign only those Agreements submitted by
applicants who are selected for participation.
The terms and conditions of participating in the Scholarship Program for the 2009-201 0 school year are set forth below.

Section A -- Obligations of the Secretary
Subject to the availability of funds appropriated by the Congress of the
United States for the Scholarship Program of the Indian Health Service
eIHS"). the Secretary agrees to provide the undersigned applicant
("applicant") with a scholarship award for the school year 2009-2010
during which the applicant must be:
L enrolled. or is accepted for enrollment, as a full-time or part-time
student in an accredited (as determined by the Secretary) educa­
tional institution in on of the several States, the District of Colum­
bia, the Commonwealth of Puerto Rico. the Commonwealth of the
Northern Mariana Islands, the Virgin Islands, Guam. or American
Samoa, and
2. pursuing a preparatory education course or curriculum necessary
for enrollment or reenrollment in a health professions school, or
3. pursuing pregraduate education leading to a baccalaureate degree
in premedicine, prenursing. predentistry, prepharmacy, prephysical
therapy, or other health profession which has been determined to
be needed by the Indian Health Service for partidpation in the
Scholarship Program.
The Scholarship award may consist of payments, in whole or in part, for
tuition, an amount of all other reasonable educational expenses incurred
by the student, and a monthly stipend for the academic period covered by
the award beginning with the first month of each school year in which
the applicant is a participant in the Scholarship Program.

Section C -- Breach of Agreement

If the applicant:
Withdraws from the educational program for any reason. or fails to
maintain an acceptable level of academic standing in the education
program for which the scholarship award is provided, the scholarship
award will be terminated and to be reinstated, the applicant will have
to apply and compete as a new applicant during the regular
application cycle.

Section D .- Extension of Scholarship Award
L The applicant may annually request extension of this scholarship
award, for a period not to exceed 12 month'S, if the request is sub­
mitted in accordance with procedure established by the Secretary.
2. Subject to the availability of funds appropriated by the Congress of
the United States for the Indian Health Service Scholarship Pro­
gram, the Secretary shall approve the request for an extension if:

Section B _. Obligations of the Applicant
The applicant agrees:

1. to accept the scholarship award provided to the Secretary under
Section(A) of this Agreement for the school year 2009-2010;
2. to maintain full-time or part-time enrollment until completion of
the course of study for which the scholarship award is provided;

:t to

4. that it is hislher intent to provide services to Indians. as a full-time
practitioner orthe profession for which the education scholarship is
awarded, upon I:ompietion of the necessary education and training.
and that it is his/her intent that these servil:es will be provided in
the Indian Health Servke. an urban Indian organization assisted
under 42 CFR, Part 36, Subdivision 1-6 or in a health professional
shortage area designated under Section 332 of the Public Health
Service Act which address the health care needs of a substantial
number of Indians as determined by the Secretary in accordance
with guidelines of the Indian Health Service

maintain an acceptable level of academic standing while en­
rolled in the course of study for which the scholarship award is
provided; and

a. The request does not extend the total period of scholarship
award beyond two (2) years for a preparatory education award
or beyond four (4) years for a pregraduate baccalaureate degree
award, and
b. The applicant is otherwise eligible for continued participation
in the Health Professions Preparatory and Pregraduate
Education Scholarship Program.

The Secretary or his/her authorized representative must sign this contract before it becomes effective.
Applicant Name (Please Print)

Secretary of Health and Human Services

IHS-817 (2/09)

Applicant's Signature

Date

Date

EF