SER: WOCNEP Scholarship Information

WOCNEP Scholarship Information

WOCNEP Scholarship Application

Dorothy Doughty Education Scholarships

2024 WOC Nursing Education Program (WOCNEP) Scholarship Application

Applications are due by May 19, 2024.

Application form:

* denotes required fields

Email Address:

*First Name:

*Last Name:

*Address:

*City:

*State:

ZipCode (5 digits):

*Phone with area code and type:

Home Work Mobile

*Southeast Region member ?
Yes No

* WOCN^® Member ID #: if no, enter 0

*Identify the WOCNEP which you are accepted and plan to attend:

Program Start Date:

Program End Date:

*Employment Status:
Full Time Part Time Other

Describe if other:

*Employer:

*Title or Role:

*Identify the type of program (full scope or specialty) in which you would like to enroll:

*Financial Impact - Expenses:

Travel (Airfare):

Mileage (@prevailing IRS rate):

Tuition:

Lodging:

*Have you been awarded any other funds for your WOC Educational Program?:

Yes No

*Are you eligible to receive tuition assistance / reimbursement from your employer?

Yes No

Describe your employer's tuition assistance program, and your plans to access these funds:

*Have you received tuition assistance / reimbursement from your employer?

Yes No

If yes, amount received

Employment History (begin with most recent)

Employer1:

Name:	Location:
From:	To:
Describe Position / duties performed

Employer2:

Name:	Location:
From:	To:
Describe Position / duties performed

Employer3:

Name:	Location:
From:	To:
Describe Position / duties performed

Education Background (begin with most recent)

Education1:

Institution Name:	Location:
Graduated:	Degree Earned:

Education2:

Institution Name:	Location:
Graduated:	Degree Earned:

Education3:

Institution Name:	Location:
Graduated:	Degree Earned:

Upon Completion of your educational program:

How many hours / week do you anticipate working with people having WOC or foot care needs?

What will be your employment status?

Full Time Part Time Unknown

In what type of practice setting will you be working?

Acute Care LongTerm HomeCare

Industry Unknown Outpatient/Clinic

Describe your anticipated role / activities as a WOC nurse (check all that apply)

WOC nurse Direct Care Consultation Education Research Product Development Policy/Procedure Development
Other

If other, please describe: (300 words or less)

Describe or provide examples of your contributions to professional and community organizations: (300 words or less)

List continuing education courses, programs and/or other professional development activities related to WOC nursing completed in the last two years: (300 words or less)

Write a brief summary of your long term career goals. Provide specific reasons for wanting to take this training: (300 words or less)

Describe your professional and personal strengths and/or attributes that will enable you to achieve your goals and enhance your role as a WOC nurse: (300 words or less)

Scholarship recipients will be solely responsible for all federal, state and/or local taxes associated with the scholarship. In the event, a recipient receives an amount of $600 or more, they will be required to sign tax documents (W-9 form) BEFORE receiving scholarship payment.

In lieu of my signature, completing this information, I hereby certify that this is a true and accurate representation of my information, activities and accomplishments.

*Type Full Name:

*Today's Date:

Note: If the form does not submit, go up the page to make sure you've completed all required fields.