2010 Utah ENA Scholarship Application Form

Name:	^*				Date:	09/05/2010
Email:	^*				Member#:	^*
Address:	^*				Home Phone:	--^*
City:	^*	State:	Zipcode:	^*	Work Phone:	--^*

* Indicates required fields

Reason for applying for Scholarship (check the appropriate box)
CATN	GENE Course	State ENA Conf.
CEN	ENCare Registration	Other (explain)
TNCC	National Assembly
ENPC	National Leadership

A specific number of points are assigned to ENA activities to determine your eligibility for scholarship monies. You must have points from at least 2 categories. Thoroughly describe how you met the qualification in each activity. If you use chapter meetings have the chapter president provide verification of participation.

You may receive up to $300 per calendar year. There are limited funds available each quarter of the year based on first come, first serve.

Category 1: ENA Participation in last 12 months

ACTIVITY

DESCRIBE PARTICIPATION

POINTS

ENA Officer, State &/or Chapter
20pts

Position:
Activity:

Active State Committee Chair
All meetings=15pts
half or more = 10pts

Position:
Activity:

Active State Committee Member
All meetings=10pts
half or more = 5pts

Position:
Activity:

Attend National &/or State ENA Conference last year
10pts

Meeting:

National ENA committee member
20pts

Position:
Activity:

Chapter meetings attended in last 12 months.
10pts each (Max 40pts)

Activity:

ENA New Member Recruitment.
5pts each (Max 15pts)

Names:

Category 2: Professional Emergency Development

ACTIVITY

DESCRIBE PARTICIPATION

POINTS

Current CEN or CFRN or CTRN
10pts each

Certification(s):

Current CATN, ENPC, GENE, or TNCC
5pts each

Certification(s):

Current Instructor, ENPC-I, ENCARE, TNCC-I
5pts each

Certification(s):

Category 3: Emergency Teaching & Involvement in last 12 months

ACTIVITY

DESCRIBE PARTICIPATION

POINTS

Giving formal lectures & topics related to emergency nursing.
15pts

Activities:

Published articles related to emergency nursing
15pts

Articles:

Projects related to emergency nursing. Please specify.
15pts

Projects:

Dollar amount based on total points
70+ points = $300
50-65 points = $200
30-45 points = $100
15-25 points = $40