PLEASE INDICATE WHICH COURSE YOU ARE APPLYING FOR

							ONCOLOGY NURSING SOCIETY CHEMOTHERAPY AND BIOTHERAPY TRAINER COURSE


                 PLEASE INDICATE WHICH COURSE YOU ARE APPLYING FOR

         April 29, 2009 San Antonio, TX - APPLICATION DEADLINE – March 06, 2009
         July 15, 2009, Pittsburgh, PA - APPLICATION DEADLINE – May 22, 2009
         November 12, 2009, Tampa, FL - APPLICATION DEADLINE – September 18, 2009


                       ‫ڤ‬APPLICATION            FORM
                      PLEASE TYPE INFORMATION IN DESIGNATED FIELDS.

Name:

Address:
Bldg/ Suite/Floor:
City:                               State:                   Zip:

Home Telephone # (          )   -            (Best time)

Work Telephone # (      )       -            (Best time)

FAX # (     )    -                                   Email

ONS Member #                                 ONS Local Chapter

Employer                    RN License number/state:


Do you currently hold an ONS Cancer Chemotherapy Provider Card? (Yes/ No)
Please provide the name of the Trainer who taught the course and the course date in which you
attended.

Name                                         Date


Which of the following best describes your employment position? (check only one)
   Staff nurse
   Advanced practice nurse
   Educator (Setting)
   Administrator
   Other (please describe):

How many years have you worked in oncology nursing?                 years

How many years have you administered chemotherapy?                  years

Nursing Education:
  Diploma
  Associates (specify)
   BS in a health related field (specify)
   Master's degree (specialty)
   Doctorate

Type of Oncology Certification
        ®
   OCN
          ®
   AOCN
   AOCNS
   AOCNP
   CPON
For the following questions you can only use the space provided. You must type the
information.

COURSE INFORMATION:

1.      State your main reason for wanting to attend the ONS Cancer Chemotherapy Trainer course.




2.      Describe your professional education teaching experience (i.e., teaching inservices, program
        development, workshops, etc.)




3.      Describe how your clinical interests relate to cancer chemotherapy administration?




4.      Summarize your experience administering chemotherapy. Please include dates, position(s)
        held and identify the setting(s).




5. One recommendation is required. Please see Recommendation Form.



               ATTACH TO THIS APPLICATION A 1-2 PAGE (MAXIMUM) RESUME


                                    APPLICATION CHECKLIST


PLEASE NOTE: If you do not meet the eligibility criteria or if any of the above items are incomplete
your application will not be reviewed and you will be ineligible for consideration as a course
participant. Thank you.


I meet the following eligibility criteria:
   ONS Member
   Licensed registered nurse
   Have a minimum of two years experience administering chemotherapy within the last 5 years
   Hold a current ONS Cancer Chemotherapy Provider Card
   Hold current oncology certification
   Have experience presenting professional nursing educational content (presentation experience
   does not include precepting)


TRAINER COURSE FEE $675. Do not send the fee with your application. You will be invoiced
when your application has been accepted
APPLICATION SUBMISSION:

Application, letter of recommendation and resume or CV may be submitted:

Electronically by sending the documents as attachments (preferred) to: educationchemo@ons.org

OR via mail to:
                  Oncology Nursing Society
                  Education Team - Chemotherapy Trainer Course
                  125 Enterprise Drive
                  Pittsburgh, PA 15275-1214



APPLICATIONS MUST REACH ONS NO LATER THAN THE DEADLINES INDICATED BELOW:


       April 29, 2009 San Antonio, TX - APPLICATION DEADLINE – March 06, 2009
       July 15, 2009, Pittsburgh, PA - APPLICATION DEADLINE – May 22, 2009
       November 12, 2009, Tampa, FL - APPLICATION DEADLINE – September 18, 2009

Applications received after the deadline date will not be reviewed and you will be ineligible as a
course participant.


My application will be complete after including the following:
   Application form completed in full
   1 – 2 page resume attached
   Completed Recommendation Form