* denotes required fields
Email Address:
*First Name:
*Last Name:
*Address:
*City:
*State:
ZipCode (5 digits):
*Phone with area code and type:
*Southeast Region member ? Yes No
* WOCN® Member ID #: if no, enter 0
*Identify the WOCNEP which you are accepted and plan to attend:
Program Start Date:
Program End Date:
*Employment Status: Full Time Part Time Other
Describe if other:
*Employer:
*Title or Role:
*Identify the type of program (full scope or specialty) in which you would like to enroll:
*Financial Impact - Expenses:
Travel (Airfare):
Mileage (@prevailing IRS rate):
Tuition:
Lodging:
*Have you been awarded any other funds for your WOC Educational Program?:
Yes No
*Are you eligible to receive tuition assistance / reimbursement from your employer?
*Have you received tuition assistance / reimbursement from your employer?
If yes, amount received
Employment History (begin with most recent)
Employer1:
Employer2:
Employer3:
Education Background (begin with most recent)
Education1:
Education2:
Education3:
Upon Completion of your educational program:
How many hours / week do you anticipate working with people having WOC or foot care needs?
Describe your anticipated role / activities as a WOC nurse (check all that apply)
If other, please describe: (300 words or less)
Describe or provide examples of your contributions to professional and community organizations: (300 words or less)
List continuing education courses, programs and/or other professional development activities related to WOC nursing completed in the last two years: (300 words or less)
Write a brief summary of your long term career goals. Provide specific reasons for wanting to take this training: (300 words or less)
Describe your professional and personal strengths and/or attributes that will enable you to achieve your goals and enhance your role as a WOC nurse: (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, go up the page to make sure you've completed all required fields.
