PLEASE PRINT OR TYPE
Part 1: General Information
First Middle Last
Street City State Zip
Phone Number: Home_________________ Work __________________
Social Security Number: _______________________________________
ARN Membership Number: ____________________ Expiration Date:______
I belong to the ____________________________District
If you are not a Tri-Level member, please answer the following questions:
I am the dependent of a Tri-Level Member: Yes ______ No _______
I am being sponsored by a Tri-Level Member: Yes ______ No _______
Part 2: Education
College Last Attended: _____________________________________
Entrance Date Specify graduation date or date last attended
Current Educational Plan
College or University you currently are attending:
Classification: Freshman_______ Sophomore_____ Junior _______ Senior______ Graduate Student ___________
Date that you expect to graduate______________________________
Cumulative Grade Point Average______________________________
Will you be attending College full time in the year for which you are applying for a scholarship?___________________________________
Part 3: Confidential Statement of Financial Condition
This year?______Amount per month._________________________
If yes, please explain.____________________________________
Part 4: Summary of Professional and Educational Goals and Achievements
Please attach a typed summary of your professional and educational goals and achievements. Please include the following areas in your summary:
a: Your resume
b: Efforts you have made to improve your rehabilitation nursing practice and delivery of care in your work setting(s).
c. Presentations or professional publications.
d. Community involvement, particularly related to advocating for individuals with disabilities.
e. List any academic, civic, professional or athletic awards.
f. Involvement in ARN at the district, state and/or national level/
g. Goals that you hope to implement with the completion of this degree.
Part 5: Rehabilitation Nursing Value Statement
Attach a description of what rehabilitation nursing means to you and why you want to advance your career in rehabilitation nursing. Include in this your strengths and weaknesses in the field of rehabilitation nursing and your vision for this specialty in the future. (250 words)
Part 6: Conduct
I have ____ have not ____ been convicted of any misdemeanor or crime. (If affirmative, please explain.)
awarded the CFARN scholarship, I shall accept it with the knowledge that said
scholarship will be revoked for good cause as determined by the committee. I
further agree to commit to work in the field of rehabilitation in the state of
Signature of Applicant Date
ATTACH A COPY OF YOUR LATEST OFFICIAL TRANSCRIPT
CFARN Scholarship Guidelines
A $1000.00 Scholarship will be awarded to a member or a nursing student at a local college who meet the following criteria:
How to apply
Complete the attached application form and submit it along with an official copy of your current GPA, the requested financial statement, one personal reference, two professional references and supportive statements to the address listed below.
Postmark Deadline: November 30, 2012
The selection of candidates will be done by the CFARN Scholarship Committee. The Scholarship will be presented at an upcoming meeting.
Send application Form and Materials to:
Italia-Lee Bright, RN, BSN, CRRN, CCM