TNA District 2 Educational Scholarship
Sponsored by: Tennessee Nurses Foundation

Application date: ______

(Deadline is March 1 extended until April 15)

BACKGROUND

Name______

FirstMiddleLastCredentials

Home address______

StreetCityStateZip

Phone______email ______

For the last 12 months:

Have you been a member of the Tennessee Nurses Association District 2? YesNo

Have you been a member of the SNA / TSNA? YesNo

EDUCATION

BSN Program currently attending: ______

Proof of current enrollment attached: Expected graduation date:______

EMPLOYMENT / JOB HISTORY

Employer______Type of work ______

Address______

Street CityStateZip

Employer ______Type of work ______

Address ______

StreetCityStateZip

LEADERSHIP ACTIVITIES

OrganizationType of ActivityDates

1.______

2. ______

3. ______

COMMUNITY SERVICES

OrganizationType of serviceDates

1. ______

2. ______

3. ______

PERSONAL OBJECTIVES

1. Describe plans for use of scholarship funds.

______

______

______

2. Describe plans for your career following completion of your BSN program

______

______

______

3. Describe plans for participation in professional leadership roles that will impact nursing practice.

______

______

______

4. Describe plans for serving your community on activities related to your new BSN – RN role.

______

______

______

Letter of recommendation attached – Faculty member

Letter of recommendation attached – TNA District 2 member

Return all material to:

Dr. Deb Chyka

635 Spring Branch Lane

Knoxville, TN 37934

THIS PORTION TO BE COMPLETED BY REFERENCE

To the Reference: We would appreciate your opinion of the above applicant for TNA District 2 Scholarship to pursue a BSN entry-level degree, or an RN to BSN degree in nursing. Return to: Deb Chyka 635 Spring Branch Lane Knoxville, TN 37934 by March 1, 2018 April 15, 2018

We are particularly interested in an evaluation of the applicant's potential for academic and professional achievement in nursing (or the nursing specialty indicated). PLEASE DO NOT use applicant's name in your written comments as this form will be blinded for review.

Excellent / Above Average / Average / Below Average / Poor / No Basis for Judgment
Intellectual ability
Imagination & Creativity
Verbal communication Skills
Writing ability
Quality of work
Nursing practice or potential for practice

Additional comments regarding character, integrity, or motivation are appreciated if pertinent. Limit typed (or written) comments to space below. DO NOT include applicants name in your comments. Write "applicant" or "he/she" instead of applicant's name.
How long have you know the applicant?

In what capacity have you known the applicant?

Recommender Name: ______TNA member? Yes No