Consent for Name Release

    The NCR WOCN may use your name during the scholarship application process. This would include sharing your application with Scholarship Review Committee and Board. Please sign this consent form. All information will be kept confidential.

    I hereby give permission for release of my name and address to determine my scholarship eligibility during the review process and, in the event that I am awarded a scholarship, my name may appear in/on Press releases, NCR WOCN and/or WOCNS website, Journal of WOCN and WOCNews.

    Scholarship Agreement Form

    I hereby agree to the policy established by the NCR WOCN. In the event I am unable to attend the WOC in Washington, within 60 days of the NIWI date all monies heretofore accepted by me will be forfeited and returned to NCR WOCN address provided to me upon acceptance of the scholarship.

    Full Name of Applicate

    Todays Date

    Eligibility Criteria

    • Active registered nurse member of the WOCN

    • Completed application - incomplete applications will not be reviewed

    • Application must be received at the NCR WOCN office by March 15

    Note: To ensure receipt of documents by the NCR WOCN office, send your application via a traceable method such as mail return receipt requested, UPS or Federal Express. It is advisable that you keep a copy of your completed application packet.

    Applicant Information

    Your Name

    Title

    Home Address

    Home Phone

    Work Phone

    Primary Email Address

    Have you attended NIWI or WOC in Washington in the past?

    YesNo

    Are you receiving any other financial support from your employer/WOCNS to attend?

    YesNo

    Clearly and succinctly address the following three criteria to be considered for this scholarship.

    Summarize your participation in political leadership activities for your profession or community in the last three years

    Summarize your past or present involvement with WOCN at a regional/affiliate/state or national level

    As a recipient of the scholarship, describe how you would commit to use the knowledge gained from WOC in Washington to further your area of practice, the NCR WOCN/WOCNS, and nursing as a profession?

    To the best of my knowledge the information contained in this application is accurate and complete.

    I understand this scholarship may not cover all costs of this event. We encourage you to pursue your interests in public policy by applying to a regional and/or national public policy committee.