RMPANA Perianesthesia Nurses Association

Member Scholarship Application

Name: ______ASPAN Membership #______Date______

Address: ______City: ______State: ______Zip Code______

Best phone # to reach you: ______E-mail______

Scholarship Applied For:

 Certification / Recertification  Professional Education / National Conference Funding / Retreat in Rockies

Scholarship Requirements:

1. RMPANA member for one year

2. Submit points earned December 1-November 30 (You may be asked to provide verification of point activity)

3. Minimum of 20 scholarship points

4. Submit anytime during year with deadline by December 1st, one application per year

5. If you received reimbursement from your institution or other source, request only expenses not covered by other source(s).

6. Multiple categories/educational programs may be submitted together to receive maximum funding for the year.

Scholarship Category / Additional Requirements
a) CPAN/CAPA Certification/Recertification; not to exceed cost or maximum $250 / 1. Copy of CPAN/CAPA Certification/Recertification
2. Proof of cost/payment
b) Professional education program or National Conference Funding; maximum $250 per year / 1. Proof of program/course completed
2. Proof of payment

Scholarship Points

Activity
(Within Last 12 Months) / Point Value
($5.00/point) / Points Earned / Date(s)
Earned
ASPAN/RMPANA Member / 10 points
Attend RMPANA/ASPAN Seminar / 10 points each seminar
Attend ASPAN National Conference / 10 points
Attend RMPANA Board meeting (non-Board member) / 5 points each meeting
Recruit new ASPAN member (verified on ASPAN website) / 5 points each member
CPAN or CAPA Certification / 10 points each certification
Certification Coach / 10 points
ASPAN, Component or District Committee member or assist Board member / 5 points each
Run for RMPANA office / 5 points
RMPANA Component, District officer or Committee Chair / 15 points each
Recruit vendor or speaker for RMPANA seminar / 5 points each recruitment
Publish article in Air Exchange/Breathline/Website
(exclusive of reports from committee chairs,
Scholarship recipients, LDI attendees) / 10 points each
RMPANA or ASPAN Seminar speaker / 15 points each
Publish article in JOPAN/Perianesthesia books / 15 points
ASPAN officer or Committee Chair / 15 points
Other**(i.e. Community Service, Coordinated PANAW activity, other certifications) / To be determined by BOD
TOTALS:
**If you have participated in RMPANA/ASPAN activities not represented here, describe and verify the activity and submit with your application for consideration by the committee.

Applicant’s Signature (electronic signature accepted): ______

E-mail or submit by mail, application, proof of payment and proof of program/certification completed to the RMPANA Treasurer by December 1st. 10/13 Scholarship App form