CBGNA Certification Scholarship Form

This is the Chicago SGNA Certification Scholarship application which offers financial assistance ($300) to CSGNA members to take the CBGNA Certification Exam or for recertification. Four scholarships are available.
Application Deadline: May 1, 2010
Criteria/Rules:

You must be an active/current member of the CSGNA.
You must not have won this scholarship within the last three years.
The scholarship is reimbursed by the CSGNA Scholarship/Awards funds.
A point system is used to determine the scholarship winners.
If there is a tie between winning members, each person will write a brief statement on how attending the conference will impact his/her educational opportunities.
If a member wins a scholarship and is then unable to attend, he/she must surrender the (non-transferable) scholarship back to CSGNA.
The member with the next highest score will receive the scholarship.
The recipient of the scholarship must pay in advance then submit proof of registration and payment, and the test results (receipts) to the CSGNA treasurer, for reimbursement of up to $300, after taking the test.
Any recipient being sponsored or reimbursed by another source, will be deemed ineligible to receive CSGNA funds.
Please indicate if you have taken the test before and whether you would join a committee this year. This will be taken into account when evaluating.
Applicants will be asked to respond to questions that reflect their commitment to their professional growth and their financial need.

Instructions:

Please fill out this form, click Submit and an email containing your application information will be sent to the appropriate board member. Or, if you wish, you may download the application in Microsoft Word format; fill it out, print and mail it to:

(This is a pdf file - if you do not have Adobe Acrobat on your computer; right click on the button and save file to your desktop; then open the file.)

Janet Fidanze, RN, CGRN
1645 W. Ogden Ave Unit 635
Chicago, IL 60612

CBGNA Certification Scholarship Application

Personal information:

First Name

Middle Initial

Last Name

Title

(check all that apply) RN BSN MSN LPN TECH

Street Address

Address (cont.)

City

State

Zip/Postal Code

Home Phone

Home FAX

E-mail

Employer information:

Organization

Street Address

Address (cont.)

City

State

Zip/Postal Code

Immediate Supervisor

Title

Work Phone

Work FAX

E-mail

Have you received a Chicago SGNA Certification Scholarship within the last 3 years?

Yes No

Are you receiving any financial aid from your employer or other sources?

Yes No

If yes, please explain:

How long have you been a member of SGNA?

years

Date of initial membership:

What professional goals may be attained when you become certified in GI?

Please indicate any demonstrations of Commitment and Leadership roles in the workplace as well as any community commitments to CSGNA/National:
Program Committee
Membership Committee
Bylaws, Policies and Procedures Committee
CSGNA Regional Officer
National Officer or National Committee
Newsletter
Marketing
Planning Committee for MultiRegional Courses
Hosted a Regional Meeting
Assisted Host of a Regional Meeting
Please enter other community commitments below:

Have you ever been a speaker at a MultiRegional Conference?

Yes No

If yes, what year?

Have you ever been a speaker at a Regional Meeting?

Yes No

If yes, what year?

Have you ever been a speaker at a Spring or Fall Course?

Yes No

If yes, what year?

I have attended Regional Meetings within the past 3 years.

I have attended MultiRegional Meetings within the past 3 years.

I have attended Spring or Fall Courses within the past 3 years.