This application is for the Chicago SGNA MultiRegional Scholarship which offers financial assistance ($300) to CSGNA members attending the MultiRegional event. Four scholarships are available.

Deadline: September 1th, 2010
Criteria/Rules:

1. You must be an active/current member of the CSGNA.
2. You must be able to go to to Schaumburg, IL the week of October 16-17, 2010
3. You must not have won this scholarship within the last three years.
4. The scholarship is reimbursed by the CSGNA Scholarship/Awards funds.
5. A point system is used to determine the scholarship winners.
6. 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.
7. If a member wins a scholarship and is then unable to attend, he/she must surrender the (non-transferable) scholarship back to CSGNA.
8. The member with the next highest score will receive the scholarship.
9. The recipient of the scholarship must pay in advance then submit proof of registration and payment (receipts) to the CSGNA treasurer, for reimbursement of up to $500, after attending the conference.
10. Any recipient being sponsored or reimbursed by another source, will be deemed ineligible to receive CSGNA funds.
11. Please indicate if you have never attended a MultiRegional meeting and whether you would join a committee this year. This will be taken into account when evaluating.
12. 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
 

CSGNA MultiRegional 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 MultiRegional 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 if you attended this MultiRegional Event?

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.