LFS Application as a Word template
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    LFS Application as a Word template LFS Application as a Word template Document Transcript

    • Please note the following: - Print or scroll to read all pages - Click anywhere and it takes you to the first box to complete 2011 Loretta Ford Scholarship sponsored by the: North Carolina Nurses Association’s Council of Nurse Practitioners administered by: The North Carolina Foundation for Nursing and The North Carolina Nurses Association Council of Nurse Practitioners $1000 Scholarship and Free Registration (to the 2011 NP Spring Symposium) Deadline for application is: Postmark by December 10, 2010. _________________________________________________________ CRITERIA 1. Completed application submitted by deadline of December 10, 2010. 2. Summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award. In this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation. 3. Two letters of reference from nursing colleagues. 4. Documented acceptance at an approved program. Preference will be given to individuals in NC programs. 5. Current NCNA member. 6. Preference given to applicant who has not been awarded this scholarship in the past.
    • 2011 Loretta Ford Scholarship sponsored by: NCNA’s Council of Nurse Practitioners In celebration of the anniversary of nurse practitioner existence in North Carolina and, in honor of the national nurse practitioner movement’s co-founder, Loretta Ford, the North Carolina Nurses Association (NCNA) Council of Nurse Practitioners established a scholarship program. The funds are administered by the North Carolina Foundation for Nursing. Selection of the recipient is determined by the Executive Committee of the Council of Nurse Practitioners. The recipient will also receive paid registration to the 2011 Nurse Practitioner Spring Symposium. The winner may participate for one or all days of the Symposium. (The winner will be responsible for Symposium travel, food and lodging.) PURPOSE This scholarship is intended to encourage registered nurses to pursue graduate level education and to enter advanced nursing practice as a nurse practitioner. CRITERIA 1. Completed application submitted by deadline of December 10, 2010. 2. Summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award. In this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation. 3. Two letters of reference from nursing colleagues. 4. Documented acceptance at an approved program. Preference will be given to individuals in NC programs. 5. Current NCNA member. 6. Preference given to applicant who has not been awarded this scholarship in the past. The scholarship recipient will be determined by the North Carolina Nurses Association Council of Nurse Practitioners Executive Committee and notified in February. The recipient will be formally recognized at the NCNA Nurse Practitioner Spring Symposium in 2011 and receive the scholarship at that time (NP Spring Symposium tuition will be paid by NCNA). Scholarship recipients who drop out of school or change majors away from the NP program must notify the NP Executive Committee immediately and will be required to repay the full amount of the award. BASIS OF AWARD The Loretta Ford Scholarship is awarded without regard to race, gender, religion, age, or national origin. The Council of Nurse Practitioners Executive Committee will give consideration to the following factors when judging applicants for the scholarship award: 1. Potential for contribution to nurse practitioner practice. 2. Participation in student, professional and/or community activities. 3. Completeness, professionalism, legibility, and accuracy of information on application. 4. Participation in NCNA. Send applications to: Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325 THE COMPLETED APPLICATION PACKAGE MUST BE POSTMARKED BY December 10, 2010.
    • Page 1 2011 Loretta Ford Scholarship Application Please note: the shaded boxes will expand as needed. Use the Tab key to move from one box to the next. Use the Enter key to make a new line. Name: (in full/with credentials)       Home address:       State of Residence:    # Years in State:       RN State License #:       NCNA membership #:       E-mail:       Home phone #: (   )    -     Business phone #: (   )    -     List, chronologically, last three Employers, Dates of Employment, and Position Titles (most recent first):                                                       List Educational Background (School and address, Dates of Completion and Degrees):                                                       Provide Name/Address of Current NP Program (attach copy of program bulletin):       Length of Program:       Estimated Date of Graduation:       List all current school and professional organization memberships/activities. Include years of participation, all offices or positions of leadership you have held and honors awarded:       List involvement in all community organizations and activities:      
    • 2011 Loretta Ford Scholarship Application – Page 2 Name of Applicant:       Have you received the Loretta Ford Scholarship in the past?       Please list other scholarships that you have received since beginning your current educational program (name, date, amount):       Add any other information which may assist the committee in reviewing your application:       TYPE APPLICATION, CAREFULLY READ THE FOLLOWING, SIGN/DATE I authorize the release of information to the Loretta Ford Scholarship Program as it relates to my academic record and character. I further relieve the releasing institution and its representative(s) of any liability attached to the submission of such information. I certify that the information provided in the above application is accurate. I agree that I will repay scholarship funds if I drop out of school during the funded year or if I change my major away from the NP program. Signature of Applicant: __________________________________________ Date: ___________ TYPE APPLICATION, SIGN/DATE, MAIL TO: Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325 Deadline to submit application is December 10, 2010.