The Mid-Atlantic Athletic Trainers Association

Bobby Gunn Student Leadership Award

APPLICANT BIOGRAPHICAL INFORMATION

To be eligible for the Bobby Gunn Student Leadership Award, the applicant must be enrolled in a CAATE-accredited Professional Athletic Training Program within District III, a student member of the NATA and the MAATA, and one who has never attended the NATA Annual Meeting and Clinical Symposia. The applicant for this award is not currently eligible for the BOC Examination and should indicate his/her intention to pursue the profession of Athletic Training as his/her means of livelihood upon graduation.

Must be typed

Name

Last First Middle

Date of Birth

College or University

Address while at college

Street or P.O. Box

City State Zip

Telephone Email

Home Address

Street or P.O. Box

City State Zip

Expected Date of Graduation

Athletic Training Major GPA Overall GPA

Current NATA student membership number

(NOTE: include photocopy of front and back of NATA membership card with this application)

How long have you been a student member of the NATA?

Bobby Gunn Student Leadership Award Recommendation

(To be completed by sponsoring Athletic Trainer)

A. Student’s Name:

Last First Middle

B. Rating: Please rank applicant comparing to other similar level AT students

Outstanding
Top 5-10% / Excellent
Top 25% / Good
Top 40% / Needs
Improvement / Unable to Judge
Punctuality and attendance
Positive attitude and enthusiasm
Self confidence
Emotional maturity
Shows respect for others
Ability to receive constructive criticism
Completes tasks as assigned
Communication skills with all appropriate personnel
Follows policies and procedures of the clinical setting
Initiative
Persistence
Leadership
Judgment
Responsibility/
Reliability
Fitness for a career in Athletic Training

C. In separate letter, please support your ratings in section B.

Submitted by:

Name: Title:

E-mail address: ______BOC Number: ______

Signature:

Academic and Other Honors and Awards Recognition

(Title and date of award, summary of award purpose)

Award Title and Date / Purpose of the award

Assigned Athletic Training Clinical Experiences

(Description of clinical experience/athletic team; responsibilities; extent of involvement/hours)

Clinical Experience / Responsibilities / Extent of involvement

Volunteer Athletic Training Experiences

(Description of experience; responsibilities; extent of involvement)

Experience / Responsibilities / Extent of involvement

Professional and Campus Memberships and Organizations

(Organization name; dates of membership; description of organization)

Name of the Organization / Date(s) of membership / Description of the Organization

Public/Community Service Activities

(Organization or activity name/summary; dates of activity)

Name of the Organization / Date(s) of membership / Description of the Organization

Leadership Positions Held

(Position held; dates; position title; organization name; indicate if this is a student organization, community service organization; athletic training or other professional organizations)

Position Held or Position Title / Organization Name / Type of Organization (i.e., student, community service, athletic training, or other) / Duties of the Position

Certifications/Licenses Held (CPR, EMT, etc.)

(List Credential/License; credentialing agency, date of issuance, certification/license # if applicable)

Credential/License / Credentialing agency / Date of issuance / Certification/
License number

Continuing Education attendance at Professional Meetings/Conference/Symposia

(Date of meeting; title of meeting or host; meeting location)

(e.g., May 2014 MAATA Conference; Virginia Beach, VA)

Title of the meeting / Date(s) / Location

Scholarly and Other Presentations

(Date of presentation; full title; authors; name of meeting/conference; indicate if the presentation was at a local, state, regional, national or international conference)

Title of Presentation / Author(s) / Meeting/Conference / Type of Meeting/Conference (local, state, regional, national, or international) / Dates of the Meeting/Conference

Scholarly Publications

(Date of publication; full paper title; name of publication)

Title of the Publication / Author(s) / Location of the Publication / Date of the Publication

*Please also attach a 500 word essay that describes your involvement in athletic training, a clear understanding of Bobby Gunn’s impact on the athletic training profession, and your athletic training leadership aspirations for the future (NOTE: for more information on Bobby Gunn, refer to the April 2007 edition of the “NATA News” online at www.nata.org in the members-only section). Your response should be a minimum of one page double-spaced using a 12-pt font.

Applicant Signature


Each candidate must forward the completed forms to the Chairperson of the MAATA Scholarship Committee by March 1st.

The MAATA Scholarship Committee will screen and evaluate each candidate’s application form and announce the award winner’s to the membership committee at its annual business meeting.

The members of the MAATA Scholarship Committee are:

Joseph A. Beckett, EdD, ATC

MAATA Scholarship Committee Chair

Marshall University

Marshall University

1 John Marshall Drive

Huntington, WV 25755

Gullickson Hall 108

Voice: 304-696-2929

Fax: 304-696-2928

E-Mail:

Eric Bengston - North Carolina Representative

Lori Bristow – Maryland Representative

Sara Pittelkau – Virginia Representative

Drue Stapleton – West Virginia Representative

Adam Weyer - South Carolina Representative

TBD – District of Columbia Representative

2016