Chesapeake Bay Society of PeriAnesthesia Nurses

SCHOLARSHIP APPLICATION

Name: Membership #

District Date

Address:

(Please include city, state & zip code)

Phone # Email: ______

Scholarship Applied For: (Limited to 2 per calendar year)

r Certification r Recertification r National Conference Funding r Professional Education

Scholarship Requirements:

1. Active CBSPAN member for the past consecutive 2 years

2. Minimum of 8 scholarship points earned (see Point Tracker System)

3. Submit only points earned within 2 years of the application date with documentation of each

point activity.

4. Accrued points may only be used once.

Scholarship Category #1 / Additional Requirements
a) $185 for CPAN/CAPA Certification / 1. Copy of CPAN/CAPA Certification
b) $125 for CPAN/CAPA Recertification / 1. Copy of CPAN/CAPA Recertification
2. 8 points required for each certification
c) $500 maximum for professional education program or conference / 1. Copy of program attended (excepting National Conference)
2.  Write an article for the newsletter, CBSPANNER, present at the fall seminar, sponsor a Component or District meeting, or serve on the Component or District board.
3.  Newsletter articles are due within 60 days of the program/conference.
d) $500 Certified Nurse to National Conference / 1. Copy of current CPAN/CAPA certification
2. Article for the CBSPANNER
3. Eligible once every three (3) years
e) $1200 for Component Excellence in Clinical Practice winner to attend National Conference / 1. Eligible once every three (3) years
SCHOLARSHIP CATEGORY # 2 / REQUIREMENTS
a) $1000 maximum for continuing nursing education in pursuit of a degree / 1. Copy of course attended
2. Proof of course completion
3. Proof of payment

SCHOLARSHIP POINTS / TRACKER

Activity / Point Value / Points Earned / Date/s Earned
CBSPAN Board Member / 3 points per year of service
District Officer / 3 points per year of service
CPAN or CAPA Certified / 3 points per certification
Publish article in JoPAN / 3 points per article
Publish article (exclusive of Committee reports or National Conf.) / 2.5 points per article in CBSPANNER or Breathline
Speaker for CBSPAN/District / 2.5 points per event
Certification Coach / 2.5 points per year
Attend Fall Seminar / 2 points per event
Host CBSPAN/District meeting / 2 points per meeting
Run for CBSPAN/District office / 2 points per election
Recruit speaker for CBSPAN /District / 2 points per speaker
CBSPAN/ASPAN committee member / 2 points per committee
Attend CBSPAN/District Board meeting (non Board member) / 1 point per meeting
Attend District meeting / 1 point per meeting
Recruit new ASPAN member / 1 point per Recruitment
Assist CBSPAN Board member / 1 point (Documentation from Board member)
Other ** / To be determined by Board
TOTALS:

** If you have participated in a District /CBSPAN /ASPAN activity not represented here, describe and provide verification with your application for consideration by the Scholarship committee

Applicant Signature:

Return this application and the points verification to the Scholarship Chairperson by January 31st and/or July 1st:

Penny Rathmanner 16 Kings Grant Road Hockessin, DE 19707

Revised: December 2013, January 2016 (chair address only)