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Mid Atlantic Region of the WOCN Educational Scholarship Application

Mid Atlantic Region of the WOCN® Educational Scholarship Application Form

The WOCN Scholarship Committee is proud to offer scholarship awards for those nurses wishing to attend an Accredited Educational Programs. Scholarship applications are accepted once yearly and must reach the Mid Atlantic Region of the WOCN chair of the scholarship committee by midnight, August 31, 2018. Applications may be submitted before program begins.
No information, either via email or US mail, will be accepted after this time - no exceptions. It is the applicant's responsibility to assure that they have met all criteria and that all requested information has been submitted in full.

Complete and submit this application form. (* Required Fields)

Applicant Information
* Name, First / Last First Name is required. Last Name is required.
* Credentials Credentials are required.
* Address Address is required.
* City / State / Zip City is required. State is required. A value is required.
* Phone, home / work Home Phone is required. Enter "None" if not employed.
* Email A valid email address is required.A valid email address is requiredA valid email address is required.
 
Identify the WOCN program which you would like to attend
  Name of Program A value is required.
  Program Start / End Dates A value is required. A value is required.
 
Identify the type of program in which you would like to enroll
 
     

Financial Impact
  Expenses: Reimbursements
    Travel $   Travel $
    Mileage (@ IRS prevailing rate)   Mileage
    Registration Fee   Registration Fee
    Room   Room
     

Have you been awarded any other awards, scholarships or grants?
*
Please select Yes or No.Please select Yes or No.
  If yes, amount of reward:
 
Are you eligible to receive or have you received tuition assistance / reimbursement from your employer?
 
Please select Yes or No.Please select Yes or No.
  If yes, amount of reward:
 
Explanation of financial need narrative: Please explain why you believe your financial need is greater than others.
* Your statement is required.
   
Employment History (begin with most recent)
1 Employer Name Location From       To Credentials and experience
   
   Position description:
 
2 Employer Name Location From       To Credentials and experience
 
   Position description:
 
3 Employer Name Location From       To Credentials and experience
   Position description:
 

Educational Background (begin with most recent)
1 Institution (name) Location (city/st/country) Graduated (mo/yr) Degree earned
 
 
2 Institution (name) Location (city/st/country) Graduated (mo/yr) Degree earned
 
 
3 Institution (name) Location (city/st/country) Graduated (mo/yr) Degree earned
 
 

Upon Completion of your educational program:
  How many hours per week do you anticipate working with people having wound, ostomy or continence needs?
 
  What will be your employment status?
Please make a selection.
 
In what type of practice setting will you be working?       
     

Will your primary care responsibilities fall within the scope of WOC nursing practice? Please explain:

Describe your anticipated role / activities as WOC nurse:





Describe:

 
Describe or provide examples of your contributions to professional and community organizations.
   
List continuing education courses, programs and/or other professional development activities related to WOC nursing you have completed in the last two years.
 
Write a brief summary of your long term career goals. Provide specific reasons for wanting to take this training
Describe your professional and personal strengths and/or attributes that will enable you to achieve your goals and enhance your role as a WOC nurse.

*Signature:

In lieu of my signature, by checking this box, I hereby certify that this is a true and accurate representation of my information, activities and accomplishments.

Check box to "sign". Click to agree.

Check here to verify information.Date: Enter today's date as: (mm/dd/yyyy).Enter today's date as (mm/dd/yyyy).



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