Nursing Degree Completion Scholarship

Genesis Health Services Foundation

Carlen Brinser Award Application

Genesis Health System Employees Only


 

Name:* 
Employee Number: * 
Address: *

City/State/Zip:* 

 , ,
Day Phone:*
Evening Phone:*
Email Address: *
Entity:*
Department/Unit:*
FTE Status: *
Years of Service:*
Are you a preceptor? * Yes     No
Name or course or seminar that you will be attending:
Name of sponsoring organization:
Location of source or seminar (City & State):
Date of course or seminar:
Number of CEU credits you will earn:

Estimated Expenses
Course Registration: $
Travel: $
Lodging: Room Rate: $     # of Nights:
Meals: $
Patient Care Area/Department Involvement: (List most recent)
     1. Name of Activity, Project or Committee:
         Date(s) of Service:
         Presenter/Poster/Champion:
         Committee Chair? Yes     No
     2. Name of Activity, Project or Committee:
         Date(s) of Service:
         Presenter/Poster/Champion:
         Committee Chair? Yes     No
     3. Name of Activity, Project or Committee:
         Date(s) of Service:
         Presenter/Poster/Champion:
         Committee Chair? Yes     No
     4. Name of Activity, Project or Committee:
         Date(s) of Service:
         Presenter/Poster/Champion:
         Committee Chair? Yes     No
Professional Organizations: (List most recent)
     1. Name of Organization:
         Member since (date):
         Officer? Yes     No
     2. Name of Organization:
         Member since (date):
         Officer? Yes     No
     3. Name of Organization:
         Member since (date):
         Officer? Yes     No
Community Involvement (List most recent)
     1. Event Name
         Date
         Leadership Role? Yes     No
     2. Event Name
         Date
         Leadership Role? Yes     No
     3. Event Name
         Date
         Leadership Role? Yes     No
Describe how attending this course or seminar will enhance your professional skills?