Foundation of the National Student Nurses' Association, Inc. In Memory of Frances Tompkins

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1 Foundation of the National Student Nurses' Association, Inc. In Memory of Frances Tompkins SCHOLARSHIP APPLICATION FOR ENROLLED NURSING STUDENTS Application is available on Click on NSNA Foundation APPLICATION MAY BE COPIED FOR DISTRIBUTION (Deadline: MUST BE RECEIVED BY January 22) ELIGIBILITY All applicants must be students currently enrolled in state-approved schools of nursing or pre-nursing* in associate degree, baccalaureate, diploma, generic doctorate, and generic master's programs. High school students are not eligible. Monies are awarded in the spring to be used in the next academic year and summer school. Monies can only be used for nursing or pre-nursing in one of the above mentioned programs. No monies can be used for graduate education unless leading to a first degree in nursing. If you are matriculating into a nursing program, letter of acceptance must accompany this application. Proof of enrollment will be required at time of award. Graduating high school seniors are not eligible. Current NSNA Board of Directors and NSNA Nominating & Elections Committee members are not eligible. *Prenursing students are students enrolled in college or university programs designed as preparation for entrance into a program leading to an associate degree, diploma or baccalaureate degree in nursing. GENERAL SCHOLARSHIPS are open to all nursing and pre-nursing students who meet the above eligibility requirements. You do not need to be a member of NSNA to apply. However, some sponsors require NSNA membership for eligibility. CAREER MOBILITY SCHOLARSHIPS are open to nursing and pre-nursing students who are registered nurses enrolled in programs leading to a baccalaureate degree with a major in nursing or licensed practical/vocational nurses enrolled in a program leading to licensure as a registered nurse. Applicants must submit a copy of their license. Seniors in Associate Degree or Diploma programs who are going immediately onto an RN to BSN or RN to Master s program must submit proof of enrollment and RN license at time award check is issued. BREAKTHROUGH TO NURSING SCHOLARSHIPS FOR RACIAL/ETHNIC MINORITIES are open to nursing or pre-nursing students who indicate on the application that they are from a disadvantaged background (including students who are racial/ethnic minorities underrepresented among registered nurses). Refer to minority groups listing. SPECIALTY NURSING SCHOLARSHIPS for students interested in specialized nursing practice. NEW--PROMISE OF NURSING SCHOLARSHIPS are available in selected regions of the US. Your school/college of nursing s zip code will determine eligibility for this new scholarship program. This program is supported by fund-raising events sponsored by Johnson & Johnson. Funds for this scholarship are supported by contributors in selected regions. If you attend nursing school in California; South Florida; Georgia; Illinois; Massachusetts; Michigan; New Jersey; Dallas/Fort Worth, Texas; or Tennessee, you may be eligible for a Promise of Nursing Scholarship. SELECTION AND NOTIFICATION OF RECIPIENTS Selection of scholarship recipients is based on academic achievement, financial need, and involvement in student nursing organizations and community health activities. All factors are equally weighted. The Selection Committee is composed of nursing faculty and students from a variety of nursing programs. Scholarship Recipients Are Notified in March. Only Winners Are Notified. Foundation of the National Student Nurses Association 45 Main Street, Suite 606, Brooklyn, NY (718) Web Site: address:

2 INSTRUCTIONS Please read this section carefully. Failure to follow all instructions will result in disqualification. No application will be considered without the following attachments: 1. $10 processing fee must accompany each application. Check or money order must be made payable to the FNSNA. Applications received with checks returned for insufficient funds or closed accounts will not be considered. 2. Students must complete Sections 1,2,3,4,6, and 7. The student's dean/director or authorized their representative must complete and sign Section Copies of nursing school and all other college transcripts must be included with the application. Transcripts do not have to bear the official stamp of the school; copies of transcripts and signed grade reports for the current semester are acceptable. 4. Members of the National Student Nurses' Association who wish to be considered for scholarships open only to NSNA members must submit proof of membership with their application. 5. Students who wish to be considered for Career Mobility Scholarships must submit a copy of their registered nurse license or practical/vocational nurse license. For students entering RN to BSN or RN to MSN programs immediately upon graduation from an Associate Degree or Diploma program, a letter of acceptance must be submitted with this application. At the time the scholarship award check is issued, proof of enrollment must be provided. The scholarship award check will be made payable to the new school (i.e. RN to BSN program) for deposit in the student s tuition account. 6. Do not include information that is not requested. Do not submit photos. PLEASE READ AGAIN - All attachments, transcripts, and processing fee must be included when you submit your application package. The Selection Committee will not accept separate documents after application has been receive. Documents arriving without the application will not be considered. RETURN THIS APPLICATION, WITH ALL REQUIRED DOCUMENTS TO: Foundation of the National Student Nurses' Association 45 Main Street, Suite 606 Brooklyn, NY APPLICATIONS MUST BE RECEIVED IN THE NSNA FOUNDATION OFFICE BY January 22. If you would like the FNSNA to acknowledge receipt of your application, please enclose a stamped selfaddressed postcard with your application. Only scholarship recipients will be notified of their selection in March. NOTE: Scholarship award checks are made payable jointly to the student and the school and sent to the student for deposit in the student s tuition account. 2

3 SECTION 1. Please clearly print or type all information. Application Number Name Mailing Address City State Zip Permanent (home) Address City State Zip Phone ( ) address Social Security Number US Citizen Yes No Date of Birth Marital Status Gender: Man Woman To Be Considered for the Breakthrough to Nursing Scholarships, please check: Black or African American American Indian or Alaska Native Hispanic or Latino Asian Native Hawaiian or other Pacific Islander Other To Be Considered for Career Mobility Scholarships, licensed practical/vocational nurses or registered nurses are eligible. Please check: RN LPN/LVN (Enclose copy of license) To be Considered for Scholarships Open Only to NSNA Members, what is your NSNA membership # Expiration Date Enclose proof of membership (copy of membership card, canceled check, credit card billing, online confirmation). To be eligible for American Association of Critical-Care Nurses scholarship, NSNA membership is required, with preference given to applicants who are also AACN members. AACN Membership # (enclose copy of AACN membership card) SECTION Current School of Nursing Street City State Zip Dean Phone number: 2. Year in School Freshman Sophomore Junior Senior 3. Expected date of Graduation: Month Year 4. Type of Program: AD Baccalaureate Diploma Other (describe) 5. Type of School: State Private 6. Are you currently: Full-time Part time Number of credits currently taking: 7. Number of credits you are planning to take Summer 2004 Fall 2004 Spring Other schools of nursing and/or colleges attended: School City State Major Degree earned Year School City State Major Degree earned Year 3

4 9. Were you ever a pre-medical student Yes No 10. Were you ever a student studying another health discipline? No Yes: Which field of study? 11. Are you a second career student? No Yes: what career? SECTION 3. If you are transferring to another school, or graduating from a Diploma or Associate Degree Program and planning to enter a Baccalaureate Program in September, please complete the following: New School Address City State Zip Attach a copy of the acceptance letter. SECTION 4. APPLICANT S CERTIFICATION I believe myself eligible to apply for a scholarship administered by the FNSNA. I certify that all statements made in this application are complete and accurate. I understand that: Falsification in my application, transcripts or other attachments will disqualify my application. Failure to follow all instructions for completing the application will render my application incomplete. All selection committee decisions are final. SIGNATURE DATE SECTION 5. DEAN/DIRECTOR S CERTIFICATION To be completed by dean/director or their authorized representative. Please answer the following: Student's need for financial assistance: Student's academic abilities (including GPA and class standing): Student's contributions to the school, community, and nursing: Other important factors you believe to be relevant to the student's application for financial assistance: I have reviewed entire application. Print Name SIGNATURE TITLE DATE Phone number address 4

5 Application Number SECTION 6. NURSING STUDENT ORGANIZATION ACTIVITIES Membership Attach copy Of membership card Elected Offices Held Name of Organization National State School Chapter Committees Served on Chairperson Served as Representative Or Delegate Community Health Activities Add activities not included in the above table: List Honors and Awards: 5

6 SECTION 7. Projected Expenses for the Coming Academic Year, Including Summer School. Student's and Dependent s Expenses Student's & Spouse/Parent s Resources NET INCOME * Only include monies that have already been approved. a. tuition, books, fees, supplies, etc. a. student's wages, tips, etc. b. spouse's/dependent s tuition b. spouse's wages, tips, etc. c. rent & utilities c. other income d. food & household supplies d. financial assistance: e. clothing, laundry, etc. -- parents' contribution f. transportation -- grants/scholarships* g. medical/dental -- loans* h. other -- VA/GI benefits -- social security benefits TOTAL EXPENSES: -- other TOTAL RESOURCES: Presently: rents owns home lives w/parents in dorm List all other scholarships you have received and amount of award. Number of School Age Dependents Are you currently serving in the Military? No Yes Indicate branch: Are there other family members attending college: No Yes NOTE: Please review your expenses and resources carefully to make sure you have included all reasonable costs that you/your family will incur during the academic year and all anticipated income. GPA (using a 4.0 scale) Area(s) of nursing practice you are interested in? (i.e. operating room, emergency room, critical care; nurse educator, etc.) On a separate page, briefly describe your professional and educational goals and how this scholarship will help you to achieve them. Put your name on attachment. Maximum 200 words. 6

7 ALL APPLICANTS MUST COMPLETE Applicant's Name (Print) Zip Code of school you attend: Zip Code of school you are transferring to (if applicable) ELIGIBILITY CHECKLIST Check applicable items only: NSNA MEMBER verification enclosed American Association of Critical-Care Nurses member verification enclosed Career Mobility (indicate) RN to BSN completion program RN to MSN completion program Breakthrough to Nursing Program Enrolled Associate Degree Diploma Baccalaureate Degree Generic Master's Generic Doctorate Planned Area Of Specialization Anesthesia Nursing Critical Care Emergency Oncology Perioperative Orthopaedic Nephrology Nurse Educator RN to BSN Other FOR OFFICE USE ONLY RATING: DO NOT WRITE BELOW THIS LINE Reminder Attach your professional and educational goals. Financial Eligible for Promise of Nursing (based on Zip Academic Code): YES NO Community Involvement Nursing Organization Activities Complete application Incomplete application Total Score 7

8 STAPLE ALL ATTACHMENTS TO THIS PAGE Please make certain that all questions on the application are answered. Have You Enclosed: $10 processing fee (check or money order payable to the FNSNA)? Proof of membership if you are a member of NSNA and/or AACN (if applicable)? Current nursing school and all past college transcripts (copies acceptable)? Letter of acceptance if you are transferring to another school? Section 5, completed and signed by your Dean/Director or their authorized representative? Description of your professional and educational goals and how this scholarship will help you to achieve them. A copy of your license if you are an RN or an LPN/LVN applying for a career mobility scholarship? A completed eligibility checklist on page 8? Post card with your return address and postage to acknowledge receipt (optional)? Do not include information that is not requested. Do not submit photos. IF ANY OF THE ABOVE DOCUMENTS ARE MISSING PLEASE DO NOT SUBMIT THIS APPLICATION IT WILL NOT BE CONSIDERED. Remember: Only completed applications received by Thursday, January 22, 2004 will be considered. Only the winners will be notified of their selection in March. Include a self addressed, stamped post care if you wish your application to be acknowledged. Scholarship winners and sponsors are recognized during the FNSNA Annual Awards Ceremony which takes place on Thursday evening, April 1, 2004, in Nashville, Tennessee during the NSNA Convention. Winners will receive an invitation to attend and instructions for their participation in the awards ceremony. Winners should check with the dean/director of their nursing program to see if funding for travel is available to attend the Awards Ceremony. Good luck on your application. Thank you for applying! Mail to: Foundation of the National Student Nurses Association 45 Main Street, Suite 606 Brooklyn, New York, Questions, contact Lauren Sperle (please review document carefully before you call) (718) Deadline Received by January 22,

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