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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


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
Are you seeking: Initial CertificationRecertification
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 attaining this certification supports the ANA Standards of Professional Performance. (ANA Nursing Scope and Standards of Practice text available in the Genesis Library)