APPLICATION FOR MnSGNA SCHOLARSHIP OR GRANT

Please indicate the scholarship you are applying for in some way (e.g. circling or highlighting)

Name ______________________________________

(RN, LPN, BSN, CGRN, Tech, Other _________)

Hospital/Employer ______________________________________________________

Address _________________________________________________________
Home/Work (please circle)

Home Phone (     )_________________________________________   

Daytime Phone (     ) _____________________

Provide the Name of your immediate supervisor: ______________________________________________

Have you been a member of MnSGNA for more than one year?  No or Yes.  
Year joined: ________

Have you received a previous scholarship? 
Yes (Year) ___________________  No (circle)

__________________________________________________________________________ 

All applications must be accompanied by a separate sheet
(please print or type) that supports your request to receive the MnSGNA Scholarship that includes all three points below:

1.  How do you support MnSGNA in function and philosophy?

2. What are your goals and objectives for attending this SGNA-affiliated program?

3. In an effort to explore/identify your resources, are you eligible for funding through your employer?