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


 

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 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 attaining this certification supports the ANA Standards of Professional Performance. (ANA Nursing Scope and Standards of Practice text available in the Genesis Library)

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