2010 Loretta Ford Scholarship
Print Form
2010 Loretta Ford Scholarship sponsored by the:
North Carolina Nurses Association’s Council of Nurse Practitioners administered by: The North Carolina Foundation for Nursing and The North Carolina Nurses Association Council of Nurse Practitioners
$1000 Scholarship *************
plus Free Registration
to the 2010 NP Spring Symposium
Deadline for application is: Postmark by December 11, 2009.
CRITERIA For 2010 LFS Scholarship 1. Complete application package, submitted by December 11, 2009 deadline, that includes application and: 2. — summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award (in this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation); 3. — two letters of reference from nursing colleagues; and 4. — document of acceptance at an approved NP program (preference will be given to individuals in NC programs). 5. Current NCNA member (in good standing). 6. Preference given to applicant who has not been awarded this scholarship in the past.
2010 Loretta Ford Scholarship In celebration of the anniversary of nurse practitioner existence in North Carolina and, in honor of the national nurse practitioner movement’s co-founder, Loretta Ford, the North Carolina Nurses Association (NCNA) Council of Nurse Practitioners established a scholarship program. The funds are administered by the North Carolina Foundation for Nursing. Selection of the recipient is determined by the Executive Committee of the Council of Nurse Practitioners. The recipient will also receive paid registration to the 2010 Nurse Practitioner Spring Symposium. The recipient may participate for one or all days of the Symposium. (The recipient will be responsible for Symposium travel, food and lodging.)
PURPOSE This scholarship is intended to encourage registered nurses to pursue graduate level education and to enter advanced nursing practice as a nurse practitioner.
CRITERIA 1. Complete application package, submitted by December 11, 2009 deadline, that includes application and: 2. — summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award (in this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation); 3. — two letters of reference from nursing colleagues; and 4. — document of acceptance at an approved NP program (preference will be given to individuals in NC programs). 5. Current NCNA member (in good standing). 6. Preference given to applicant who has not been awarded this scholarship in the past. The scholarship recipient will be notified in February. The recipient will be formally recognized at the NCNA Nurse Practitioner Spring Symposium in April and receive the scholarship at that time (NP Spring Symposium tuition will be paid by NCNA). Scholarship recipients who drop out of school or change majors away from the NP program must notify the NP Executive Committee immediately and will be required to repay full amount of the award.
BASIS OF AWARD The Loretta Ford Scholarship is awarded without regard to race, gender, religion, age, or national origin. The Council of Nurse Practitioners Executive Committee will give consideration to the following factors when judging applicants for the scholarship award: 1. 2. 3. 4.
Potential for contribution to nurse practitioner practice Participation in student, professional and/or community activities Completeness, professionalism, legibility, and accuracy of information on application. Participation in NCNA.
Type, print, mail application by December 11, 2009 to:
Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325
2010 Loretta Ford Scholarship Application (Type, Print, Mail) Name: (in full/with credentials) ___________________________________________________________________________________ Home address: _____________________________________________________________________________________________ State of Residence: _________________
# Years in State: _________________
RN State License #: ______________________ NCNA membership #: ________________________
E-mail: _____________________________________________________
Home phone #: ________________________________ Business phone #: _________________________________ List, chronologically, last three Employers, Dates of Employment, and Position Titles (most recent first): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List Educational Background: (School and address, Dates of Completion and Degrees) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Provide Name/Address of Current NP Program: (Attach copy of program bulletin) ___________________________________________________________________________________________________________
Length of Program:
______________________________ Estimated Date of Graduation: _________________________
List all current school and professional organization memberships/activities. Include years of participation, all offices or positions of leadership you have held and honors awarded. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
List involvement in all community organizations and activities. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
2010 Loretta Ford Scholarship Application — Page 2 Name of Applicant: _____________________________________
Have you received the Loretta Ford Scholarship in the past? ____ Yes ____ No Please list other scholarships that you have received since beginning your current educational program (name, date, amount): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
Add any other information which may assist the committee in reviewing your application. ___________________________________________________________________________________________________________
I authorize the release of information to the Loretta Ford Scholarship Program as it relates to my academic record and character. I further relieve the releasing institution and its representative(s) of any liability attached to the submission of such information. I certify that the information provided in the above application is accurate. I agree that I will repay scholarship funds if I drop out of school during the funded year or if I change my major away from the NP program.
Signature of Applicant: ____________________________________________ Date: _____________
TYPE Application, Print, Sign/Date, Mail to:
Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325
Deadline to submit application is December 11, 2009.
2010 Loretta Ford Scholarship sponsored by the:
North Carolina Nurses Association’s Council of Nurse Practitioners administered by: The North Carolina Foundation for Nursing and The North Carolina Nurses Association Council of Nurse Practitioners
$1000 Scholarship *************
plus Free Registration
to the 2010 NP Spring Symposium
Deadline for application is: Postmark by December 11, 2009.
CRITERIA For 2010 LFS Scholarship 1. Complete application package, submitted by December 11, 2009 deadline, that includes application and: 2. — summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award (in this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation); 3. — two letters of reference from nursing colleagues; and 4. — document of acceptance at an approved NP program (preference will be given to individuals in NC programs). 5. Current NCNA member (in good standing). 6. Preference given to applicant who has not been awarded this scholarship in the past.
2010 Loretta Ford Scholarship In celebration of the anniversary of nurse practitioner existence in North Carolina and, in honor of the national nurse practitioner movement’s co-founder, Loretta Ford, the North Carolina Nurses Association (NCNA) Council of Nurse Practitioners established a scholarship program. The funds are administered by the North Carolina Foundation for Nursing. Selection of the recipient is determined by the Executive Committee of the Council of Nurse Practitioners. The recipient will also receive paid registration to the 2010 Nurse Practitioner Spring Symposium. The recipient may participate for one or all days of the Symposium. (The recipient will be responsible for Symposium travel, food and lodging.)
PURPOSE This scholarship is intended to encourage registered nurses to pursue graduate level education and to enter advanced nursing practice as a nurse practitioner.
CRITERIA 1. Complete application package, submitted by December 11, 2009 deadline, that includes application and: 2. — summary statement of no more than 250 words prepared by the applicant which demonstrates qualifications for the award (in this statement, address why you decided to pursue the NP role, your professional goals, and your plans after graduation); 3. — two letters of reference from nursing colleagues; and 4. — document of acceptance at an approved NP program (preference will be given to individuals in NC programs). 5. Current NCNA member (in good standing). 6. Preference given to applicant who has not been awarded this scholarship in the past. The scholarship recipient will be notified in February. The recipient will be formally recognized at the NCNA Nurse Practitioner Spring Symposium in April and receive the scholarship at that time (NP Spring Symposium tuition will be paid by NCNA). Scholarship recipients who drop out of school or change majors away from the NP program must notify the NP Executive Committee immediately and will be required to repay full amount of the award.
BASIS OF AWARD The Loretta Ford Scholarship is awarded without regard to race, gender, religion, age, or national origin. The Council of Nurse Practitioners Executive Committee will give consideration to the following factors when judging applicants for the scholarship award: 1. 2. 3. 4.
Potential for contribution to nurse practitioner practice Participation in student, professional and/or community activities Completeness, professionalism, legibility, and accuracy of information on application. Participation in NCNA.
Type, print, mail application by December 11, 2009 to:
Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325
2010 Loretta Ford Scholarship Application (Type, Print, Mail) Name: (in full/with credentials) ___________________________________________________________________________________ Home address: _____________________________________________________________________________________________ State of Residence: _________________
# Years in State: _________________
RN State License #: ______________________ NCNA membership #: ________________________
E-mail: _____________________________________________________
Home phone #: ________________________________ Business phone #: _________________________________ List, chronologically, last three Employers, Dates of Employment, and Position Titles (most recent first): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List Educational Background: (School and address, Dates of Completion and Degrees) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Provide Name/Address of Current NP Program: (Attach copy of program bulletin) ___________________________________________________________________________________________________________
Length of Program:
______________________________ Estimated Date of Graduation: _________________________
List all current school and professional organization memberships/activities. Include years of participation, all offices or positions of leadership you have held and honors awarded. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
List involvement in all community organizations and activities. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
2010 Loretta Ford Scholarship Application — Page 2 Name of Applicant: _____________________________________
Have you received the Loretta Ford Scholarship in the past? ____ Yes ____ No Please list other scholarships that you have received since beginning your current educational program (name, date, amount): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
Add any other information which may assist the committee in reviewing your application. ___________________________________________________________________________________________________________
I authorize the release of information to the Loretta Ford Scholarship Program as it relates to my academic record and character. I further relieve the releasing institution and its representative(s) of any liability attached to the submission of such information. I certify that the information provided in the above application is accurate. I agree that I will repay scholarship funds if I drop out of school during the funded year or if I change my major away from the NP program.
Signature of Applicant: ____________________________________________ Date: _____________
TYPE Application, Print, Sign/Date, Mail to:
Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325
Deadline to submit application is December 11, 2009.
