RCN Foundation Professional Bursary Scheme

Application Form

Please fully complete all relevant sections. We are unable to process your application if details are missing. Applications should normally be typed. If this is not possible, please use black ink.

For further details please refer to the Professional Bursary Scheme Application Guidance and Information forms.

SECTION 1: Details of educational activity for which funding is sought

Title of the proposed activity/course for which you are seeking funding (25 words max)
Click here to enter text. /
Brief summary of the activity/course and professional outcomes (100 words max)
Click here to enter text.
Start date (month and year) / Duration
Click here to enter text. / Click here to enter text. /
If you are seeking funding for a course, please state here the name and address of the course provider:
Click here to enter text. /
Have you been awarded a place? YES/NO (delete as appropriate)
Is this course or module a component of a longer course?
YES/NO (delete as appropriate)
If YES, please state:
(a) the name of the longer course:Click here to enter text.
(b) where this component is in the timetable (e.g. 1st year of 3):Click here to enter text.
(c) how the rest has been/will be funded:Click here to enter text.

SECTION 2: Details of costs of proposed activity

(a) Have you sought funding from your employer? YES/NO (delete as appropriate)
If YES, please give details, in the budget section below.
If NO, please give the reason:Click here to enter text.
(b) Are you seeking funding from any other source?YES/NO (delete as appropriate)
If YES, please give details of sources, items and outcomes if known. Please include amounts in the budget below:Click here to enter text.

(c) Please provide a detailed budget breakdown (see Application Guidance formfor example). Be as accurate and detailed as possible. Include clarification of costing in ‘notes’ section.If successful, you will need to provide evidence of costs in order to be reimbursed.

A / B / C
Item / Amount you are asking us to fund / Amount you will fund from elsewhere (please state sources) / Personal contribution
Click here to enter text. /
Click here to enter text. /
Click here to enter text. /
Click here to enter text. /
Click here to enter text. /
Subtotal
TOTAL COST OF ACTIVITY:(add columns A + B + C) £
Notes:
Click here to enter text.
(d) If you receive less than the amount you are asking us for, could you still proceed?YES/NO (delete as appropriate)
(e) If you are seeking reimbursement for staff replacement costs, have you completed section 6c of this form?YES/NO (delete as appropriate)
(f) Have you previously received an award from the RCN or RCN Foundation?
YES/NO (delete as appropriate)
If yes please state amount, date and which bursary or award you received:

SECTION 3: Employment Details

Current Employment
Job Title:
Click here to enter text. / Start date (month and year):
Click here to enter text. / Band/Grade:
Click here to enter text.
Name and Address of Employer:
Click here to enter text.
Brief description of present role:
Click here to enter text.
Previous Posts: (Please list, starting with the most recent. Add extra rows if necessary):
Name and Address of Employer / Job Title / Band/Grade / Dates
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

SECTION 4: Courses and Qualifications

Please list all courses taken starting with the most recent (Add extra rows if necessary):
Title of course: / From: Month and year / To: Month and year / Name and Address of Institution / Result
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Please list courses not yet completed (Add extra rows if necessary):
Title of course: / From: Month and year / To: Month and year / Name and Address of Institutions
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

SECTION 5: Statement by applicant in support of request for funds

Referring to the Professional Bursary Scheme Application Guidance form for further advice please provide a statement in response to the questions below (1,500 words max)
  1. What are your professional goals and how will the activity contribute to your career development?
  2. How will the activity improve the health and well-being of patients and/or carers?
  3. How will you share your learning and development with colleagues or other nursing teams?
  4. How have you demonstrated your commitment to self-development so far in your career?
  5. What challenges do you foresee in completing this activity and how do you plan to address them (for example time constraints, work-place support, financial)?
Click here to enter text.

SECTION 6: Supporting References

6a. Reference from your Manager (Please ask your Manager, or if you are not working, are self employed or are seeking funding for a career change, an alternative appropriate professional reference such as a past tutor, to complete and sign this section).
Please comment on how the proposed study would fit in with the applicant’s role and professional development and how this activity and its implementation will be supported, e.g. with mentoring or opportunities to influence practice.(As all applications are anonymised please do not refer to the applicant by name).
Click here to enter text.
Manager’s Name:Click here to enter text.
Job Title:Click here to enter text.
Signature:Click here to enter text.
Date:Click here to enter text.
6b. Additional supporting reference from an Academic Supervisor for Masters level and above only. Please ask your academic referee to complete and sign this section.
Please comment on how the applicant has previously managed in undertaking study and how the applicant will be supported to undertake the proposed study. (As all applications are anonymised please do not refer to the applicant by name).
Click here to enter text.
Academic Referee’s Name: Click here to enter text.
Job Title: Click here to enter text.
Signature:Click here to enter text.
Date:Click here to enter text.
6c. Staff Replacement – Manager sign off (Please ask your manager to complete and sign this section only if you are applying for reimbursement of staff replacement costs).
Please comment on the staff replacement arrangements that will be in place whilst the applicant undertakes study such as paying for replacement staff whilst they are on paid study leave. Where possible, provide confirmation of the costs calculations provided in section 2.
Click here to enter text.
Manager’s Name:Click here to enter text.
Job Title:Click here to enter text.
Signature:Click here to enter text.
Date:Click here to enter text.

SECTION 7: Personal Details and Application Agreement

I am a:
(please tick) / Registered Nurse☐ Registered Midwife ☐HCA/AP☐
Surname:Click here to enter text. / First Name: / Title:
Address for correspondence: / Work telephone:
Home telephone:
Mobile:
Email:
NMC Pin Number(if applicable):Click here to enter text.
Are you a member of the RCN? YES/NO(delete as appropriate)
If yes, please provide your RCN membership number:Click here to enter text.
I confirm I have read the Terms and Conditions and agree to abide by them. I agree to provide a written report either during or on completion of the funded activity or to return funds on withdrawal from the funded activity.
Signature:Click here to enter text.Date:Click here to enter text.

If you are successful, the RCN Foundation may wish to publicise your success and/or your work to the media. Please tick the box if you are NOT happy for your name and place of work to be used for this purpose.☐

Please send one signed original and four copies of your entire application by post to arrive no later than 5pm on Thursday 23 May 2013 to:

Awards Officer

RCN Foundation

20 Cavendish Square

London W1G 0RN

SECTION 8: Equal Opportunities

Completion of this section is helpful to ensure that we are aware of the communities applying for this scheme and assists in the implementation of equal opportunities. This information will not form any part of the selection process.

(Please tick the appropriate boxes).

a. Your Ethnic Group

Asian or Asian British / Mixed
Indian / ☐ / White and Black Caribbean / ☐ /
Pakistani / ☐ / White and Black African / ☐ /
Bangladeshi / ☐ / White and Asian / ☐ /
Any other Asian background / ☐ / Any other mixed background / ☐ /
Black or Black British / White
Caribbean / ☐ / British / ☐ /
African / ☐ / Irish / ☐ /
Any other Black background / ☐ / Any other White background / ☐ /
Chinese / ☐ / Any other ethnic group / ☐ /

b. Your Gender

Female☐ Male☐

c. Sexual Orientation

Bisexual☐ Gay☐Heterosexual☐ Lesbian☐Other☐

d. Your Disability

Do you have a disability?YES/NO (delete as appropriate)

e. Your Age

Under 20☐ 20-29☐ 30-39☐ 40-49☐ 50-59☐ 60-65☐65-69☐70 and over☐

1