KAREN O’NEIL
SCHOLARSHIP FUND APPLICATION
Name:___________________________ Credentials:______ ENA#/Exp. Date ________
Address:__________________________________________Chapter:_______________
Phone#: (H)__________(C)___________(W)__________Employer ________________
Reason applying for Scholarship: Check appropriate box: TNCC____ENPC____CEN____ENCARE____
National ENA Scientific Assembly _____ National Leadership Conference __________
NERS_____Other ENA-Sponsored Activity: Please Specify ______________________
ALL APPLICATIONS MUST BE RECEIVED IN ADVANCE OF THE ENA SPONSORED PROGRAM. SCHOLARSHIP RECIPIENTS WILL RECEIVE THEIR AWARD UPON SUCCESSFUL COMPLETION OF THE COURSE.
SEND APPLICATION/VERIFICATION TO THE SCHOLARSHIP EDUCATION COMMITTEE CHAIRPERSON MASSACHUSETTS ENA:
Gina Crocker vmcc55@adelphia.net
39
01913-5738
A brief explanation as to why you would like to attend this conference/workshop:
ญญญญญ
A specific number of points have been
assigned to the following activities for the purpose of
determining eligibility for scholarship awards. You must
have points from at least 2 categories. If you use
chapter meetings as part of the criteria you must have chapter
president sign your application. Indicate how you meet
the qualification on the line next to the activity.
ENA Officer: State or Chapter____________________________________ 20 ____
Committee Chair: State or Chapter_________________________________ 15 ____
Committee Member: State or Chapter_______________________________ 5 ____
(Plus 5 points each committee meeting)______________________ 5 ____ National ENA Involvement:______________________________________ 10 ____
Chapter Meetings Attendance (10 points/meeting)_____________________ 10 ____
State Council Chapter Rep/Meetings Attendance (10 points/meeting)______ 10 ____
New Member as of current calendar year____________________________ 10 ____
Current CEN, TNCC, ENPC, FAEN Please specify and list # ____________ 5 ____
Current TNCC-I, ENPC-I, ENCARE-I Please specify __________________ 10 ____
Attendance at ENA sponsored seminars (2 points/day)__________________ 2 ____
(Please specify)_________________________________________________
Presenting formal lectures on topics related to ENA____________________ 10 ____
Serving as a preceptor/mentor in emergency nursing____________________ 5 ____
Published Articles on emergency nursing_____________________________ 10 ____
Projects: Public Education, Legislative Involvement, Other_______________ 10 ____
Nursing Award or Special Recognition_______________________________ 5 ____
(Please specify all categories above)
Points: Category 1: _____
Category 11: _____
Category 111: _____
*AWARD
WILL BE AWARDED ACCORDING TO TOTAL POINTS
*EACH MENA MEMBER
WILL BE ELIGIBLE FOR
ONE SCHOLARSHIP PER
CALENDER YEAR
>
75 points = $100
>
50 points = $ 75
>
25 points = $ 50
Signature of applicant:___________________________________ Date:_____________
Signature of chapter president: ____________________________ Date:_____________
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Thank you for your application and dedication to Emergency Nursing.
MENA 2/08