* denotes required fields
*Email Address:
*First Name:
*Last Name:
*Credentials:
*Address:
*City:
*State:
*ZipCode (5 digits):
*Phone with area code and type:
*WOCN® Member ID #:
*Southeast Region member ? Yes No
*WOCN Education Program from which you graduated:
Date Graduated:
*Content of WOC Education Program from which you graduated (check all that aply):
*Identify the type of program (full scope or specialty) in which you would like to or have enrolled:
*After graduation, will your primary care responsibilities be within the scope of WOC Nursing?: Yes No Please explain: (300 words max)
*Financial Impact - Expenses:
Travel (Airfare):
Mileage (@prevailing IRS rate):
Tuition:
Lodging:
*Are you eligible to receive tuition assistance / reimbursement from your employer?
Yes No
Describe your employer's tuition assistance program, and your plans to access these funds: 300 words or less
*Have you received tuition assistance / reimbursement from your employer?
If yes, amount received
*Have you been awarded any other funds for your Advanced Practice Educational Program?:
*Employment Status: Full Time Part Time Other Describe if other:
*Employer:
*Current Title or Role:
Percentage of time spent in WOC Nursing activities
What is your Practice Setting (check all that apply)
Acute Care Long Term Home Care Industry Outpt/Clinic Other
*Employment History (begin with most recent)
Employer1:
Employer2:
Employer3:
*Education Background (begin with most recent)
Education1:
Education2:
Education3:
List professional and community organizations to which you belong and offices held or committee participation: (300 words or less)
List professional awards or honors received: (300 words or less)
Provide specific reasons for seeking advanced education: (300 words or less)
Describe your professional and personal strengths that will contribute to your success: (300 words or less)
Scholarship recipients will be solely responsible for all federal, state and/or local taxes associated with the scholarship. In the event, a recipient receives an amount of $600 or more, they will be required to sign tax documents (W-9 form) BEFORE receiving scholarship payment.
In lieu of my signature, completing this information, I hereby certify that this is a true and accurate representation of my information, activities and accomplishments.
Type Full Name:
Today's Date:
Note: If the form does not submit, scroll up the page to make sure you've completed all required fields.
