Nursing Degree Completion Scholarship

Genesis Health Services Foundation

Marilyn Willits Nursing Certifications Scholarship Application

Genesis Health System Employees Only

Click here to read the Eligibility Requirements and Terms of Scholarship.

Click here to read about Marilyn Willits, MS, RN CPHQ

 

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
Are you seeking: Initial Certification     Recertification
Name of Certification that you are pursuing:
Name of Certifying organization:
Cost of Certification Registration:
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 you are viewed as a person who lives the Genesis Standards of Behavior and influences others to improve the image of professional nursing.

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