ONS Genetics Short Course for Cancer Nurses APPLICATION

ONS Genetics Short Course for Cancer Nurses APPLICATION

PLEASE NOTE: Only completed applications received by the stated deadlines are reviewed. First consideration is given to applicants who are active ONS members. Applicants are required to be oncology nurses with an advanced Master’s and/or Doctoral nursing degree.

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Please indicate which course(s) you are applying to attend.

Note: Courses will close earlier than the stated deadlines if seats are filled.

March 24-26, 2006, Pittsburgh, PA – (DEADLINE January 10, 2006)

May 6-8, 2006, New Orleans, LA – (DEADLINE January 31, 2006)

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Please TYPE or PRINT clearly all information:

Name:

(First)(M.I.)(Last)(Credentials)

Home Address:

City: State: Zip Code:

Employed by:

Work Address:

City: State: Zip Code:

Home Phone Number:()Best time to call:

Work Phone Number: () Ext Best time to call:

Fax Number: () E-Mail (*required):

Setting (Please check all that apply):

Inpatient Outpatient Hospice Home CareRadiationSchool of Nursing

Other (Please describe):

Position Title: Certifications:

Are you an active ONS member? Yes No ONS # (if applicable):

Number of Years in Nursing:

Number of Years in Oncology Nursing:

Highest Nursing degree completed:

Highest non-Nursing degree completed:

Ethnic Group: African American Asian Hispanic/Latino Native American

Caucasian Other: Do Not Care to Respond

Please state your main reasons for wanting to attend this course. Limit your response to the space provided.

STATEMENT OF AGREEMENT

If I am accepted to this course, I agree to the following:

1.Complete pre-work and post-test (six hours maximum) assigned in preparation for attending program. Deadlines for pre-work completion are March 10, 2006 for the March 24-26, 2006 course; and, April 21, 2006 for the May 6-8, 2006 course.

2.Attend and actively participate in the entire course as follows:

- March 24-26, 2006 course - Friday, March 24, 2006,10am-5pm; Saturday, March 25, 2006, 8:30am-5:00pm; and Sunday, March 26, 2006, 8:30am-4pm. Do not scheduled airline flight out of Pittsburgh, PA, prior to 6pm, Sunday, March 26, 2006.

-May 6-8, 2006 course - Saturday, May 6, 2006,11am-6pm; Sunday, May 7, 2006, 8am-4pm; and Monday, May 8, 2006, 7am-3pm. Do not scheduled airline flight out of New Orleans, LA, prior to 6pm, Monday, May 8, 2006.

3.Complete all written program evaluations, project updates, and final reports.

4.Complete the competency examination (minimum score of 75%) within six weeks of completing the Genetics Short Course for Cancer Nurses.

5.Disseminate the knowledge gained in the Genetics Short Course for Cancer Nurses by delivering a one 4-hour workshop on basic and cancer genetics to other nurses in your local area, within six months of certification.

6.Actively share information from the program and serve as a role model and mentor to others.

7.Make airline reservations and hotel reservations (excludes the March 24-26, 2006). ONS will reimburse a maximum of $400 for airfare and meals for the March 24-26, 2006 course. ONS will make hotel reservations for the attendees at the March 24-26, 2006 course. ONS will reimburse a maximum of $1000 for airfare, meals, and hotel expenses for the May 6-8, 2006 course.

8.Meet the course requirements including being an oncology nurse who has completed an advanced Master’s and/or Doctoral nursing degree.

9.Receive reimbursement after returning both the Genetics Short Course exam and the completed travel reimbursement form with original receipts to the ONS National Office.

(Signature of applicant) (Date of application)

Please submitthe application and signed Statement of Agreement to:

Oncology Nursing Society

Education/Cancer Care Issues Team (ECCIT)

ATTN: Annette M. Parry Bush

Genetics Short Course for Cancer Nurses

125 Enterprise Drive

Pittsburgh, PA 15275-1214

Applications must reach ONS by 5pm, ET, of the stated deadlines.

Note: Courses will close earlier than the stated deadlines if seats are filled.

January 10, 2006 for the March 24-26, 2006 course

January 31, 2006 for the May 6-8, 2006 course

Applications and the signed statement of agreement can be emailed to ECCIT ()

Please Do Not Fax your application.

An emailconfirmation is sent within three business days after application is received.

You will be notified of your acceptance six weeks before the scheduled course dates.