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Genesis Health Services Foundation

Carlen Brinser Award Application

(For attendance at a nursing conference or seminar during 2015)

Genesis Health System Employees Only


Last Name:* 
First Name:* 
Middle Initial:* 
Employee Number: * 
Address: *

City/State/Zip:* 

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

In 300-400 words, describe how attending this conference or seminar supports ANA Standards of Professional Performance and how you will integrate the findings into practice. (ANA Nursing Scope and Standards of Practice text is available in the Genesis Library.)