Ellen Boyda Education/Professional Conference Scholarship
PURPOSE
This scholarship was established in 1997 to honor Ellen Boyda, a charter member of the SePA Chapter. SePA encourages the educational advancement of its members and also promotes attendance at critical care nursing related conferences and programs. Scholarship funds may be utilized to support members completing a baccalaureate or graduate degree in nursing, as well as towards registration, travel, hotel, etc. costs for approved programs such as AACN’s National Teaching Institute or SePA’s TRENDS in Critical Care Nursing Conference.
CRITERIA
Recipients of this scholarship must be active SePA Chapter members as defined by the accumulation of point totals from the Point Evaluation Form. The funded amount is based upon points accrued for involvement in chapter activities within the immediate past chapter fiscal year (July to June).
AWARD
Dollar amounts are individually awarded per point submitted from the Point Evaluation Form based upon the total number of approved points received from all applicants per year. There are no longer options to rollover or bank points, thus all unused funds will be forfeited. The award is considered a reimbursement for approved professional activities that occurred during the same fiscal year the application is submitted.
ELIGIBILITY
-Active RN license
-Current AACN and SePA memberships
-Submit completed application packet: REQUEST FOR FUNDING FORM (PART 1)
POINT EVALUATION FORM (PART 2)
-Submit valid receipts for approved activities that occurred during the applicable fiscal year
TOAPPLY
Obtain application instructions and materials from the Nursing Network website under the Engagement Committee tab and email all completed documents to . Applications must be received by midnight on June 1st.
IMPORTANT!
Income from scholarships/awards are taxable and must be reported to the IRS -
A W9 Form will be provided by the Treasurer
REQUEST FOR FUNDING FORM (PART 1)
Submission Date: ______
Name: ______Last 4 digits of SSN: ______
Address: ______
Preferred Phone #: ______RN License #: ______
AACN Membership #: ______Expiration date: ______
SePA Membership #: ______Expiration date: ______
EDUCATION ADVANCEMENT REQUEST
Name of Academic Institution: ______
Name of Program/Degree Pursued: ______
Date of Matriculation: ______Date of Expected Graduation: ______
PROFESSIONAL CONFERENCE / CONTINUING EDUCATION PROGRAM REQUEST
1. Title: ______Date: ______
2. Title: ______Date: ______
OTHER: ______
POINT EVALUATION FORM (PART 2)
Instructions for completing:
- Complete a Point Evaluation Form for all activities that occurred during the immediate past chapter fiscal year (July to June).
- When completing each item, please include point totals in each box provided. Whenever possible, scoring guidelines are included in each item to assist calculating point totals for each item.
- Be sure to provide ALL required information on point evaluation forms. For example, include a copy of certification card to accompany item #13. Points will not be counted for incomplete or inaccurate items.
- Completed applicationsmust be received at o later than midnight on June 1st. Any application received after the deadline will not be reviewed.
- Keep a copy of all forms submitted for your own records.
Submission Date: ______
Name: ______Last 4 digits of SSN: ______
1.SePA Chapter Board of Director (BOD) positions:
President (150 points) ______
President Elect (75 points) ______
Secretary (50 points) ______
Treasurer (100 points) ______
Treasurer Elect (50 points) ______
Education Committee Chair (100 points) ______
Education Committee Chair Elect (50 points) ______
Research Committee Chair (100 points) ______
Research Committee Chair Elect (50 points) ______
Engagement Committee Chair (100 points) ______
Engagement Committee Chair Elect (50 points) ______
Board Member (25 points) ______
2.SePA Chapter Subcommittee Lead positions: (20 points for each)
Education:
Education Programs ______
Certification/SACOR ______
TRENDS ______
Engagement:
Membership ______
Communications ______
Awards and Scholarships ______
BOD Nominations ______
Research:
Research Education ______
Research Dinner Program ______
Research Posters ______
Research Grants ______
3.Other SePA Chapter position(s) not listed above that you would like to be
considered: (20 points for each)
______
4.Attendance and participation at SePA Chapter meetings, events, programs,
etc. Please be descriptive and list the dates: (10 points for each)
BOD: ______
______
Education: ______
______
Engagement: ______
______
Research: ______
______
Other not listed above that you would like to be considered: ______
5.Attendance and participation at the annual SePA Chapter Strategic Planning
Meeting:(40 points)
Date: ______
6.SePA Chapter or National AACN lecturer for which you did not receive an
honorarium, compensation, or reimbursement: (50 points for each)
Title of Lecture, Event:Date:
______
______
7.SePA Chapter or National AACN poster presenter for which you did not
receive an honorarium, compensation, or reimbursement: (50 points for each)
Title of Poster, Event:Date:
______
______
8.Article published in a professional nursing journal:(75 points for each)
Article Citation:
______
______
9.Content contributed toa SePANOTES Newsletter: (20 points for each)
Article Title:Date/Edition:
______
______
10.SePA Chapter new member recruitment:(20 points for each)
Full Name:Date Joined:
______
______
11.Position on National AACN committee or taskforce: (50 points for each)
Position:Dates Served:
______
______
12.Valued active SePA Chapter member:
0-5years of membership – 25 points
6-10 years of membership – 50 points
>11 years of membership – 75 points
13.National professional nursing certification such as CCRN, PCCN, CCNS,
ACNPC-AG, etc. Please include a copy of your certification card(s):
(25 points for each)
Certification:Date of Expiration:
______
______
14.Other SePA Chapter activities that you would like to be considered which
demonstrate your commitment and involvement to the chapter. Please be as
specific as possible: (5 points for each)
Activity:Date: ______
______
______
______
15.TRENDS Planning Committees:
Activities / Available Points / Your PointsNurse Planner /
- Overall nurse planner
Speaker Committee /
- Create the call for abstracts, conduct the review and selection process, revise the speaker packet, notify and maintain correspondence with speakers
Members: 25
Program/Brochure Committee /
- Design the program/brochure, edit and ensure accuracy of all details, coordinate printing and distribution via mail and electronically
Members: 25
Sponsorship/Exhibit Committee /
- Develop the exhibit prospectus, distribute to past exhibitors, maintain correspondence with exhibitors, set up registration, and assist on-site with exhibit hall set up
Members: 25
Registration Committee /
- Determine costs and set up registration, coordinate for mail-in registration, maintain correspondence with attendees who have registration questions, assist with on-site registration
Members: 25
Volunteer Committee /
- Solicit availability of past volunteers, create the volunteer grid, set up registration, and assist on-site as needed
Members: 25
Venue Committee /
- Review and select a suitable facility, conductbasic contract negotiation for submission to AACN for review (including hotel room block, food and beverages, AV equipment, etc.), assign sessions rooms, create signage, assist on-site as needed
Members: 25
Total TRENDS Planning Committee Points ______
Please read and sign the following statement:
I, , certify to the best of my knowledge, that the above information concerning my activities with the SePA Chapter of AACN is correct.
TOTAL POINTS SUBMITTED:
SIGNATURE: DATE: