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					            Foundation of the National Student Nurses' Association, Inc.
                                     In Memory of Frances Tompkins
     SCHOLARSHIP APPLICATION FOR ENROLLED NURSING STUDENTS
               Application is available on www.nsna.org Click on NSNA Foundation


                    APPLICATION MAY BE COPIED FOR DISTRIBUTION
                      (Deadline: MUST BE RECEIVED BY January 31)
ELIGIBILITY
All applicants must be students currently enrolled in state-approved schools of nursing or pre-nursing* in
associate degree, baccalaureate, diploma, generic doctorate, and generic master's programs. High school
students are not eligible. Monies are awarded in the spring to be used in the next academic year and
summer school. Monies can only be used for nursing or pre-nursing in one of the above mentioned
programs. No monies can be used for graduate education unless leading to a first degree in nursing. If you
are matriculating into a nursing program, letter of acceptance must accompany this application. Proof of
enrollment will be required at time of award. Graduating high school seniors are not eligible. Current
NSNA Board of Directors and NSNA Nominating & Elections Committee members are not eligible.
*Prenursing students are students enrolled in college or university programs designed as preparation for
entrance into a program leading to an associate degree, diploma or baccalaureate degree in nursing.

GENERAL SCHOLARSHIPS are open to all nursing and pre-nursing students who meet the above eligibility
requirements. You do not need to be a member of NSNA to apply. However, some sponsors require NSNA
membership for eligibility.

CAREER MOBILITY SCHOLARSHIPS are open to nursing and pre-nursing students who are registered
nurses enrolled in programs leading to a baccalaureate degree with a major in nursing or licensed
practical/vocational nurses enrolled in a program leading to licensure as a registered nurse. Applicants must
submit a copy of their license. Seniors in Associate Degree or Diploma programs who are going
immediately onto an RN to BSN or RN to Master’s program must submit proof of enrollment and RN license
at time award check is issued.

BREAKTHROUGH TO NURSING SCHOLARSHIPS FOR RACIAL/ETHNIC MINORITIES are open to
nursing or pre-nursing students who indicate on the application that they are from a disadvantaged
background (including students who are racial/ethnic minorities underrepresented among registered nurses).
Refer to minority groups listing.

SPECIALTY NURSING SCHOLARSHIPS for students interested in specialized nursing practice.

NEW--PROMISE OF NURSING SCHOLARSHIPS are available in selected regions of the US. Your
school/college of nursing’s zip code will determine eligibility for this new scholarship program. This
program is supported by fund-raising events sponsored by Johnson & Johnson. Funds for this scholarship
are supported by contributors in selected regions.

                  ALL APPLICANTS ARE AUTOMATICALLY CONSIDERED FOR ALL
                        SCHOLARSHIPS FOR WHICH THEY ARE ELIGIBLE.

SELECTION AND NOTIFICATION OF RECIPIENTS Selection of scholarship recipients is based on
academic achievement, financial need, and involvement in student nursing organizations and community
health activities. All factors are equally weighted. The Selection Committee is composed of nursing faculty
and students from a variety of nursing programs.

              Scholarship Recipients Are Notified in March. Only Winners Are Notified.
                       Foundation of the National Student Nurses’ Association
                     45 Main Street, Suite 606, Brooklyn, NY 11201 (718) 210-0705
               Web Site: www.nsna.org general e-mail address: receptionist@nsna.org
                                                 INSTRUCTIONS

Please read this section carefully. Failure to follow all instructions will result in disqualification. No
application will be considered without the following attachments:

       1. $10 processing fee must accompany each application. Check or money order must be made
          payable to the FNSNA. Applications received with checks returned for insufficient funds or closed
          accounts will not be considered.

       2. Students must complete Sections 1,2,3,4,6, and 7. The student's dean/director or authorized
          their representative must complete and sign Section 5.

       3. Copies of nursing school and all other college transcripts must be included with the application.
          Transcripts do not have to bear the official stamp of the school; copies of transcripts and signed
          grade reports for the current semester are acceptable.

       4. Members of the National Student Nurses' Association who wish to be considered for scholarships
          open only to NSNA members must submit proof of membership with their application.

       5. Students who wish to be considered for Career Mobility Scholarships must submit a copy of their
          registered nurse license or practical/vocational nurse license. For students entering RN to BSN
          or RN to MSN programs immediately upon graduation from an Associate Degree or Diploma
          program, a letter of acceptance must be submitted with this application. At the time the
          scholarship award check is issued, proof of enrollment must be provided. The scholarship award
          check will be made payable to the new school (i.e. RN to BSN program) for deposit in the
          student’s tuition account.

       6. Do not include information that is not requested. Do not submit photos.


         PLEASE READ AGAIN - All attachments, transcripts, and processing fee must be included
         when you submit your application package. The Selection Committee will not accept
         separate documents after application has been receive. Documents arriving without the
         application will not be considered.

                 RETURN THIS APPLICATION, WITH ALL REQUIRED DOCUMENTS TO:

                            Foundation of the National Student Nurses' Association
                                           45 Main Street, Suite 606
                                             Brooklyn, NY 11201


                                  APPLICATIONS MUST BE RECEIVED
                           IN THE NSNA FOUNDATION OFFICE BY January 31.

 If you would like the FNSNA to acknowledge receipt of your application, please enclose a stamped self-
 addressed postcard with your application. Only scholarship recipients will be notified of their
 selection in March.

 NOTE: Scholarship award checks are made payable jointly to the student and the school and
 sent to the student for deposit in the student’s tuition account.




                                                          2
                                                                          Application Number___________
SECTION 1. Please clearly print or type all information.

Name
Mailing Address
City                                                                State                 Zip
Permanent (home) Address
City                                                                State                 Zip
Phone (           )                         e-mail address

Social Security Number _________________________US Citizen  Yes                     No

Date of Birth                         Marital Status               Gender: Man          Woman

►To Be Considered for the Breakthrough to Nursing Scholarships, please check:
 Black or African American  American Indian or Alaska Native  Hispanic or Latino
 Asian  Native Hawaiian or other Pacific Islander  Other

►To Be Considered for Career Mobility Scholarships, licensed practical/vocational nurses or registered
nurses are eligible. Please check:  RN        LPN/LVN (Enclose copy of license)

►To be Considered for Scholarships Open Only to NSNA Members, what is your
NSNA membership #                    Expiration Date
Enclose proof of membership (copy of membership card, canceled check, credit card billing, online confirmation).

►To be eligible for American Association of Critical-Care Nurses scholarship, you must be a member of the
  AACN. Membership #                                (enclose copy of AACN membership card)

SECTION 2.
1. Current School of Nursing
Street
City                                                                State          Zip
Dean                                                       Phone number:_______________________
2. Year in School      Freshman               Sophomore       Junior                Senior
3. Expected date of Graduation: Month_____ Year _______
4. Type of Program:  AD  Baccalaureate  Diploma
     Other (describe) _____________________________
5. Type of School:  State  Private
6. Are you currently:  Full-time  Part time Number of credits currently taking: _____________
7. Number of credits you are planning to take Summer 2003_____Fall 2003______Spring 2004______
8. Other schools of nursing and/or colleges attended:

School                                                             City                  State
Major____________________ Degree earned _____________________________Year___________
School                                                             City                  State
Major____________________ Degree earned _____________________________Year___________

                                                       3
9. Were you ever a pre-medical student Yes  No
10. Were you ever a student studying another health discipline?
    No Yes: Which field of study? ________________________________________________

11. Are you a second career student? No Yes: what career?_____________________________
SECTION 3. If you are transferring to another school, or graduating from a Diploma or Associate Degree
Program and planning to enter a Baccalaureate Program in September, please complete the following:

New School
Address
City                                                                     State          Zip

►Attach a copy of the acceptance letter.

SECTION 4. APPLICANT’S CERTIFICATION I believe myself eligible to apply for a scholarship
administered by the FNSNA. I certify that all statements made in this application are complete and
accurate. I understand that:

► Falsification in my application, transcripts or other attachments will disqualify my application.
► Failure to follow all instructions for completing the application will render my application incomplete.
► All selection committee decisions are final.

SIGNATURE                                                                        DATE
SECTION 5. DEAN/DIRECTOR’S CERTIFICATION To be completed by dean/director or their
authorized representative. Please answer the following:

►Student's need for financial assistance:



►Student's academic abilities (including GPA and class standing):



►Student's contributions to the school, community, and nursing:



►Other important factors you believe to be relevant to the student's application for financial assistance:




I have reviewed entire application. Print Name_____________________________________________
SIGNATURE                                                 TITLE                         DATE
Phone number                                      E-mail address


                                                     4
                                                              Application Number___________

SECTION 6. NURSING STUDENT ORGANIZATION ACTIVITIES

                      Name of Organization         National    State      School Chapter

Membership
Attach copy
Of membership card

Elected
Offices Held



Committees
Served on



Chairperson



Served as
Representative
Or Delegate




Community
Health
Activities




►Add activities not included in the above table:




►List Honors and Awards:




                                                     5
SECTION 7.

                                                               Student's & Spouse/Parent’s Resources
 Projected Expenses for the Coming Academic Year,                           NET INCOME
             Including Summer School.
                                                              * Only include monies that have already
     Student's and Dependent’s Expenses                       been approved.



 a. tuition, books, fees, supplies, etc.                      a. student's wages, tips, etc.
 b. spouse's/dependent’s tuition                              b. spouse's wages, tips, etc.
 c. rent & utilities                                          c. other income
 d. food & household supplies                                 d. financial assistance
 e. clothing, laundry, etc.                                   -- parents' contribution
 f. transportation                                            -- grants/scholarships*
 g. medical/dental                                            -- loans*
 h. other                                                     -- VA/GI benefits
                                                              -- social security benefits
 TOTAL EXPENSES:                                              -- other


                                                              TOTAL RESOURCES:




 ►Presently:  rents         owns home        lives w/parents   in dorm
 ►List all other scholarships you have received and amount of award.




 ►Number of School Age Dependents__________
 ►Are you currently serving in the Military?  No  Yes Indicate branch:_________________
 ►Are there other family members attending college: No Yes
 NOTE: Please review your expenses and resources carefully to make sure you have included all
 reasonable costs that you/your family will incur during the academic year and all anticipated income.


►GPA (using a 4.0 scale)
►Area(s) of nursing practice you are interested in? (i.e. operating room, emergency room, critical care; nurse
educator, etc.)_____________________________________________________________________________

►On a separate page, briefly describe your professional and educational goals and how this
scholarship will help you to achieve them. Put your name on attachment. Maximum 200 words.
ALL APPLICANTS MUST COMPLETE
                                                       6
Applicant's Name (Print)

Zip Code of school you attend: _______________________________________

Zip Code of school you are transferring to (if applicable) __________________

                                     ELIGIBILITY CHECKLIST

Check applicable items only:
                                                   Planned Area Of Specialization

 NSNA MEMBER verification enclosed                 Anesthesia Nursing

 American Association of Critical-Care             Critical Care
  Nurses member verification enclosed
                                                    Emergency
 Career Mobility
                                                    Oncology
 Breakthrough to Nursing
                                                    Operating Room

Program Enrolled                                    Orthopaedic

 Associate Degree                                  Nephrology

 Diploma                                           Nurse Educator

 Baccalaureate Degree                             ___________________

 Generic Master's                                 ___________________

 Generic Doctorate                                ___________________

 RN to BSN

Other_____________________________                Reminder – Attach your professional and
                                                              educational goals.

DO NOT WRITE BELOW THIS LINE
FOR OFFICE USE ONLY
RATING:
_________Financial                                 Eligible for Promise of Nursing (based on Zip

_________Academic                                  Code):    YES        NO

_________Community Involvement                      Complete application
_________Nursing Organization Activities            Incomplete application
_________Total Score


                                               7
                        STAPLE ALL ATTACHMENTS TO THIS PAGE

Please make certain that all questions on the application are answered.

Have You Enclosed:

 $10 processing fee (check or money order payable to the FNSNA)?
 Proof of membership if you are a member of NSNA and/or AACN (if applicable)?
 Current nursing school and all past college transcripts (copies acceptable)?
 Letter of acceptance if you are transferring to another school?
 Section 5, completed and signed by your Dean/Director or their authorized representative?
 Description of your professional and educational goals and how this scholarship will help you to
achieve them.
 A copy of your license if you are an RN or an LPN/LVN applying for a career mobility scholarship?
 A completed eligibility checklist on page 8?
 Post card with your return address and postage to acknowledge receipt (optional)?

                  Do not include information that is not requested. Do not submit photos.



                   IF ANY OF THE ABOVE DOCUMENTS ARE MISSING –
         PLEASE DO NOT SUBMIT THIS APPLICATION—IT WILL NOT BE CONSIDERED.


Remember:
► Only completed applications received by Friday, January 31, 2003 will be considered.

► Only the winners will be notified of their selection in March.

► Include a self addressed, stamped post care if you wish your application to be acknowledged.
Scholarship winners and sponsors are recognized during the FNSNA Annual Awards Ceremony which
takes place on Thursday evening, April 24, 2003, in Phoenix, Arizona during the NSNA Convention.
Winners will receive an invitation to attend and instructions for their participation in the awards
ceremony. Winners should check with the dean/director of their nursing program to see if funding for
travel is available to attend the Awards Ceremony.

                         Good luck on your application. Thank you for applying!

                                                  Mail to:
                         Foundation of the National Student Nurses’ Association
                                        45 Main Street, Suite 606
                                      Brooklyn, New York, 11201
          Questions, contact Lauren Sperle (please review document carefully before you call)
                                           (718) 210-0705

                           Deadline—Received by January 31, 2003



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