ANAC

ASSOCIATION OF

NURSES IN AIDS CARE

2009 ANAC Student Diversity Mentorship Scholarship

NOMINATION FORM OVERVIEW

Description:

The goals of the Student Diversity Mentorship Scholarship are:

  • To recognize a student nurse from a diverse racial or ethnic background who has a genuine interest in HIV/AIDS Nursing and is interested in attending the ANAC national conference.
  • To establish a mentor/mentee relationship with the recipient that will continue to develop after the conference.

The recipient of this award will receive a $1,000 Nursing scholarship, up to $599 in travel reimbursement (if attending), free conference registration ($395.00, attending), free awards ceremony admission, an award plaque, and a one-year ANAC membership.

Members of the ANAC Diversity Specialty committee will serve as the official guide/host for the recipient while attending the conference. A member of the Diversity Specialty committee will be assigned as the recipient’s official mentor and will maintain contact with the student after the conference. The mentor will be assigned after the recipient is selected to ensure that the best mentee / mentor match is made.

Nominating Criteria and Instructions:

  • Nominees may be recommended by self, nursing faculty, or local ANAC chapter members. Each nomination must be supported by an ANAC member.
  • Nominee must be a member of a racial or ethnic minority group and currently enrolled in an accredited nursing program. Verification of enrollment will be required.
  • Students at the entry, undergraduate and graduate level of nursing may apply (i.e. LPN, ADN, Diploma, BS/BSN, or MS/MA programs in nursing). PLEASE NOTE THAT DOCTORAL STUDENTS (PhD, DNP, DSN, DNSc) ARE NOT ELIGIBLE FOR THIS SCHOLARSHIP.
  • Nominees must submit a typed essay, no more than 500 words, describing their interest or experience in HIV/AIDS care and why they want to attend the ANAC conference.
  • Current ANAC National Board members, ANAC National staff and Awards Committee members are NOT eligible.

Completed forms and required supporting documentation must be received in the ANAC office no later than June 30, 2009. Please submit all documents via email to Jennifer Liehr at , by fax at 330-670-0109 or by mail (3538 Ridgewood Road, Akron, Ohio 44333). Late or incomplete nominations will not be accepted for review.

Selection Process

A five member sub-committee made up of representatives from the conference host city chapter (1), the conference committee (1), and the diversity specialty committee (3) will review the nominations and select the recipient of this award. Selection will be made based on quality of essay and experience or interest in HIV/AIDS care, prevention, or education. The recipient will be notified by August, 2009. The award recipient of this scholarship will be recognized during the Awards Ceremony at the 2009 22nd Annual ANAC Conference in Jacksonville, Florida in November 19-22, 2009.

2009 ANAC Student Diversity Mentorship Scholarship

NOMINATION FORM

The Association of Nurses in AIDS Care (ANAC) Student Diversity Mentorship Scholarship recognizes a student nurse from a diverse racial or ethnic background who has a genuine interest in HIV/AIDS Nursing and is interested in attending the organization’s national conference.

Completed forms and required supporting documentation must be received in the ANAC office no later than June 30, 2009. Please submit all documents via email to Jennifer Liehr at , by fax at 330-670-0109 or by mail (3538 Ridgewood Road, Akron, Ohio 44333). Late or incomplete nominations will not be accepted for review.

Nominee’s Name:

Home Address:

City: State: Zip: Daytime Phone:

E-mail:

Racial/Ethnic group (Check all that apply):

African-American American Indian/Alaskan Native

Asian/Pacific Islander Hispanic/Latino Other( )

Currently enrolled in Program:

College/University:

Address:

City: State: Zip:

Degree pursuing: Major/Specialty:

Years attended: Completed credits:

Anticipated graduation date:

Please attach ALL of the following items:

  1. A typed 500 word personal statement by the applicant, describing his/her interest or experience in HIV/AIDS care and why they want to attend the ANAC conference. Please keep the personal statement to fewer than 500 words to be considered.
  2. Signed statement of support from an active ANAC member supporting the nomination.
  3. Official transcripts from the nursing program of enrollment.
  4. The applicant’s statement of intent to attend the Awards Ceremony at the 2009, 22nd Annual ANAC Conference in Jacksonville, Florida in November 19-22, 2009.

NOMINATION FORM continued

This nomination is supported by the following ANAC Member:

Name:

ANAC ID number:

Address:

Current position:

Describe your association with the nominee:

Consent to be Considered as a Nominee for the

2009 ANAC Student Diversity Mentorship Scholarship

I hereby agree to be considered as a nominee for the Student Diversity Mentorship Scholarship

Signature of Nominee Date ______

Phone: Work ______Home ______

Email ______

I plan to attend the 2009 Awards Ceremony at the 22nd Annual ANAC Conference in Jacksonville, Florida in November (19-22) if selected for this award.

Yes No

Completed forms and required supporting documentation must be received in the ANAC office no later than June 30, 2009. Please submit all documents via email to Jennifer Liehr at , by fax at 330-670-0109 or by mail (3538 Ridgewood Road, Akron, Ohio 44333). Late or incomplete nominations will not be accepted for review.

3538 RIDGEWOOD ROAD, AKRON, OHIO 44333(TEL) 330-670-0101

(FAX) 330-670-0109

(800) 260-6780