Eastern North Carolina Society for GI Nurses and Associates

Application for Grant Money – 2017 to 2018

The purpose of this form is to identify applicants as potential recipients for grant money. This form will need to be completed and returned to the current regional secretary via US Mailon or before January 1, 2018. You will be notified by letter and/or telephone by February 15,2018of the requesting year if you have or have not been selected to receive grant money. ALL Applications must be complete in order to be considered. Grant recipients must be able to account for all grant money and return any unused grant money to the ENCSGNA.

GRANT REQUIREMENTS: You must be a member of SGNA for both the past year and current year (2017 and 2018).

You MUST have attended ONE Regional Conference in 2017.

SECTION I:

Application Date: ______Name: ______

Address: ______

Telephone (Home): ______(Work) ______Email: ______

Employer: ______Department: ______Current position: ______

I am requesting $______in grant money for ONE of the following:

 Attend Annual Course**  Certification  Recertification  Endoscopy Technician Certification

 Attend ENCSGNA Spring and Fall Regional Conference  Education for career advancement (CMA/RMA, LPN, RN, ADN, BSN, MSN, DNP)

*Note: only one request per person will be granted per calendar year. ** If you are granted money to attend the SGNA National Conference you will be expected to participate at the conference: as a speaker, present a poster/abstract, attend Regional Leadership or House of Delegatesor be a moderator of at least 1 session.

SECTION II: / Scoring / Total Points
How long have you been a member of SGNA?
REQUIREMENT: You must be a member of SGNA for both the past year and current year (2017 – 2018). / 1-5 yrs  1 points
>5yrs  3 points
>10 years  5 points
Active participation in ENCSGNA in the last year
You might be requested to provide copies of certificate(s)/letters, etc before grant application is reviewed.
REQUIREMENTS: You MUST have attended ONE Regional Conference in the past TWO years. / Attended Spring or Fall Regional Conference  2 points
Attended both Spring and Fall Regional Conference  5 points
Board Member  3 points
Committee Chair  2 points
National SGNA Position  5 points
Speaker at Regional Conference  3 points
Speaker at National Conference  5 points
Moderator at National Conference  5 points
Presenting a Poster at National Conference (current) 5 points
SGNA Scholars or Fellow’s Program  5 points
SGNA Mentor or Mentee  5 points
Have you received money from ENCSGNA in the past 5 years? / No  5 points
Yes  2 points
Organized and planned ENCSGNA educational event within the last 5 years
Attach verification letter from event coordinator / Single Speaker event DATE:______ 5 points
Full day course DATE:______ 10 points
Certified in GI - RN or Technician certification / Yes  5 points
No  0 points
Active Participation in GI Education, Event or Community Outreach Program within the last 3 years
Attach verification letter from event coordinator or registration form / Published - Article or Research Project  5 points
Coordinated a GI Community Event  5 points
Speakers at GI Community Event  3 points
Participant at GI Community Event Speaker  2 points
Minimum Score is 10 / Total:

SECTION III: Briefly explain to The ENCSGNA Board, how this grant money will positively influence your advancement in the field of Gastroenterology.

FOR ENCSGNA USE ONLY

Date Postmarked: / Date Received:
 Approved /  Denied Reason:
 Granted Money Amount: ______Check #: /  Not Granted

ENCSGNA Grant Application Check List

Please ensure your application has all the supporting documentation for the following items

Check if added to the application packet / Items that must be included in your application packet
Copy of your 2017 SGNA Membership Card
Copy of your 2018 SGNA Membership Card
Copy of your ENCSGNA 2017 Fall or Spring Conference CE Certificate (or both)
Copy of CGRN Certification or Copy of GI Endoscopy Technician Certification (or both)
Copy of SGNA National Position
Registration information or Letter to confirm participation in GI Event with date of event
Certification or paid registration for SGNA National Conference 2017
Brochure that notes your presentation at a GI Event – National or Regional or Community
Information that you have participated in the SGNA Mentor/Mentee Program
SGNA Email with National Conference Moderator Assignment
Poster or Abstract Acceptance from SGNA
Letter of Acceptance from SGNA into Scholars or Fellow’s Program
Copy of Published Article or Research Project
SGNA Committee Verification
Verification of your coordination in a community event
If requesting grant money for education for career advancement please provide a letter of acceptance into an educational program: CMA/LPN/AND/BSN/MSN or DNP

Please retainall originals of your Grant Application and submit copies of all forms via U.S Postal Service to:

ENCSGNA Grant Application 2018

C/O Kathryn Lyons

318 Reynolds Ave, Durham, NC 27707

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