2011Loretta Ford Scholarship

sponsored by the:

North Carolina Nurses Association’s Council of Nurse Practitioners

administered by:

The North Carolina Foundation for Nursing andThe North Carolina Nurses Association

Council of Nurse Practitioners

$1000 Scholarship* * * * * * * * * * * * *

plus Free Registrationto the 2011 NP Spring Symposium

Deadline for application is: Postmark by December 10, 2010.

CRITERIA For 2011 LFS Scholarship

1. Complete application package, submitted by December 10, 2010 deadline, that includes application and:

2. — summary statement of no more than 250 words prepared by the applicant which demonstratesqualificationsfortheaward(inthisstatement,addresswhy you decided to pursue the NP role, your professional goals, and your plans after graduation);3. — two letters of reference from nursing colleagues; and4. —documentofacceptanceatanapprovedNPprogram(preferencewillbegivento individuals in NC programs).5. CurrentNCNAmember(ingoodstanding).6. Preference given to applicant who has not been awarded this scholarship in the past.

2011 Loretta Ford ScholarshipIn celebration of the anniversary of nurse practitioner existence in North Carolina and, in honor of the national nursepractitionermovement’sco-founder,LorettaFord,theNorthCarolinaNursesAssociation(NCNA)Coun-cil of Nurse Practitioners established a scholarship program.

The funds are administered by the North Carolina Foundation for Nursing. Selection of the recipient is deter-mined by the Executive Committee of the Council of Nurse Practitioners. The recipient will also receive paid registration to the 2011 Nurse Practitioner Spring Symposium. The recipient may participate for one or all days oftheSymposium.(TherecipientwillberesponsibleforSymposiumtravel,foodandlodging.)

PURPOSE This scholarship is intended to encourage registered nurses to pursue graduate level education and to enter advanced nursing practice as a nurse practitioner.

The scholarship recipient will be notifiedinFebruary.TherecipientwillbeformallyrecognizedattheNCNANursePractitionerSpringSymposiumin2011andreceivethescholarshipatthattime(NPSpringSymposiumtuition will be paid by NCNA).

Scholarship recipients who drop out of school or change majors away from the NP program must notify the NP Executive Committee immediately and will be required to repay full amount of the award.

BASIS OF AWARD The Loretta Ford Scholarship is awarded without regard to race, gender, religion, age, or national origin. The Council of Nurse Practitioners Executive Committee will give consideration to the following factors when judg-ing applicants for the scholarship award:

1. Potential for contribution to nurse practitioner practice2. Participation in student, professional and/or community activities3. Completeness, professionalism, legibility, and accuracy of information on application.4. Participation in NCNA.

Send application by December 10, 2010 to: Loretta Ford Scholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325

1. Complete application package, submitted by December 10, 2010 deadline, that includes application and:2. — summary statement of no more than 250 words prepared by the applicant which demonstrates

qualificationsfortheaward(inthisstatement,addresswhyyoudecidedtopursuetheNProle,your professional goals, and your plans after graduation);

3. — two letters of reference from nursing colleagues; and4. —documentofacceptanceatanapprovedNPprogram(preferencewillbegiventoindividualsin

NC programs).5. CurrentNCNAmember(ingoodstanding).6. Preference given to applicant who has not been awarded this scholarship in the past.

CRITERIA

2011 Loretta Ford Scholarship ApplicationPlease Type

Name:(infull/withcredentials)___________________________________________________________________________________

Homeaddress:_____________________________________________________________________________________________

StateofResidence:_________________ #YearsinState:_________________

RNStateLicense#:______________________

NCNAmembership#:________________________ E-mail:_____________________________________________________

Homephone#:________________________________Businessphone#:_________________________________

List,chronologically,lastthreeEmployers,DatesofEmployment,andPositionTitles(mostrecentfirst):

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

ListEducationalBackground:(Schoolandaddress,DatesofCompletionandDegrees)

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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ProvideName/AddressofCurrentNPProgram:(Attachcopyofprogrambulletin) ___________________________________________________________________________________________________________

Length of Program: ______________________________EstimatedDateofGraduation:_________________________

Listallcurrentschoolandprofessionalorganizationmemberships/activities.Includeyearsofparticipation,allofficesorpositions of leadership you have held and honors awarded.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Listinvolvementinallcommunityorganizationsandactivities.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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HaveyoureceivedtheLorettaFordScholarshipinthepast?____Yes____No

Pleaselistotherscholarshipsthatyouhavereceivedsincebeginningyourcurrenteducationalprogram(name,date,amount):

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Add any other information which may assist the committee in reviewing your application.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

IauthorizethereleaseofinformationtotheLorettaFordScholarshipProgramasitrelatestomyacademicrecordandcharacter.Ifurtherrelievethereleasinginstitutionanditsrepresentative(s)ofanyliabilityattachedtothesub-mission of such information.I certify that the information provided in the above application is accurate. I agree that I will repay scholar-ship funds if I drop out of school during the funded year or if I change my major away from the NP program.

SignatureofApplicant:____________________________________________Date:_____________

TYPEApplication,Sign/Date,Mailto: LorettaFordScholarship NC Foundation for Nursing 103 Enterprise Street Raleigh, NC 27607-7325

Deadline to submit application is December 10, 2010.

2011 Loretta Ford Scholarship Application — Page 2Name of Applicant: _____________________________________