Leadership Nursing
Scholarship Application
Background
First Name Last Name
Home Address
Home Phone Email
How many years have you lived in your community?
Are you a registered voter? Yes No
Employment Information
Employer
Work Address
Work Phone Email
Position Years with Employer?
Name of your Immediate Supervisor
Has your employer agreed to pay your tuition?
Yes
No
Partial
As a participant in a leadership program, you will be expected to attend all the planned sessions for their entirety. Do you and your employer support this expectation?
Yes
No If no, explain
Program Details and Specifics
Locating a program is the responsibility of the applicant. This portion of the application deals with the details of this program. In order to be considered for a scholarship, these questions MUST be answered.
Program Title:
Program Sponsor:
Program Date(s):
Program Web Site (optional):
Program Registration Fee:
Please enter any additional comments about the program here:
Community Involvement
List, in order of importance, up to five community, civic, professional, business, religious, social, athletic, and/or other organizations in which you are an active member and how you have demonstrated leadership in these organizations.
1= Most Important 5= Least Important
1
2
3
4
5
Approximately how many hours do you volunteer each month?
Opinions
What do you consider your highest career/volunteer achievement or responsibility?
What characteristics do you have that suggest you will be a leader in organizations which play a significant role in the community?
What do you hope to gain from participating in a leadership program?
What ideas do you have for future community service? (e.g. seeking public office, volunteer leadership, serving on boards and commissions, etc.)
Note: This questionnaire must be submitted no less than 8 weeks prior to the application deadline of the leadership program for which you wish to receive a Leadership Nursing Scholarship.
