Conference Scholarship for Nursing Students Submission Form Return to description Fields marked with an asterisk (*) are required. CONTACT INFORMATION First and last name * Credentials (If applicable) Primary email * Mailing address * Mailing address 2 City, State. Zip * Primary phone * YOUR JOB & EMPLOYER Job title * Employer * ABOUT YOU Are you certified? Ambulatory Care Coordination Telehealth Other Please select all that apply. Other - please describe What is your highest level of education? * - Select -ADNRNBSNMastersDoctorateOther, please describe below) Other education, please describe * What is your degree in? * - Select -NursingBusinessHealth relatedOther, please describe below Other degree, please describe * Are you a member of any other professional organizations? * - Select -NoYes, if so, which organizations Please list organizations * AAACN & YOU Are you a member of AAACN * - Select -Yes - Less than 1 yearYes - 1-3 yearsYes - 4-6 yearsYes - 7-10 yearsYes - 10+ yearsNo, I am not a member of AAACN If you answered "Yes" above, please complete fields A-D below that are applicable to you A. What volunteer committees, task forces, etc., have you participated in for AAACN? B.How do you promote AAACN? C. Number of AAACN Conferences attended in the past? D. Year and number of presentations given at AAACN Conference(s), including poster presentations? SCHOLARSHIP SPECIFIC INFORMATION The rest of this form contains information that is specifically for the Conference Scholarship for Nursing Students. ACADEMIC INSTITUTION INFORMATION Name and Address of Academic Institution * Institution name: Address: City, State, Zip: Please submit proof of your student status. * Upload More informationFiles must be less than 8 MB. Allowed file types: pdf doc docx. What degree are you seeking? * ADN RN BNS Select all that apply. LETTER OF RECOMMENDATION AND VIEWPOINT Name of current AAACN member recommending you for this scholarship * Submit a letter for recommendation from current AAACN member. * Upload More informationFiles must be less than 2 MB. Allowed file types: pdf doc docx. Write for the ViewPoint Publication * - Select -YesNoI am willing to write an article for the ViewPoint publication within one year of receipt of the award describing my journey from nursing school graduation to competence in the profession of nursing. Additionally, will include a description of the professional benefits I have derived from this award. NARRATIVE (50-100 WORDS) As you begin your career in nursing, please select and respond to one of the four statements below to be included as part of your application. Select your statement * - Select -1. State how you expect ambulatory practice to be part of your career.2. State how you expect the benefits of attending the AAACN annual conference will assist you in your career.3. State your vision of promoting the art and science of ambulatory care nursing.4. State your goals for your professional nursing career and broadly describe how you plan to meet those goals. Your Response (50-100 Words) * SIGNATURE AND DATE The information provided in this application is accurate and complete. I understand that acceptance of an AAACN award, scholarship, or research grant obligates me to use the funds awarded for the intent described in this application. I further understand that misuse of a AAACN award, scholarship, or research grant may result in permanent revocation of my AAACN membership and a requirement that I refund any misused funds to AAACN. All information contained in this application will be considered confidential and will be reviewed only by members of the Nominating Committee of AAACN and staff. All applications are blinded by staff before they are sent to the Nominating Committee for consideration. Your electronic signature * Date * IMPORTANT: At any stage of filling out this form, please ONLY use the buttons directly below this text to complete any action. Leave this field blank Preview Your Submission
