2023 Special Scholarship Application

Applying for: (Check one)(Required)

EN 23Other CE Conference

General Information - All applicants complete this section.

Your First Name (required)

Your Last Name (required)

Your Credentials (required)

Your Street Number and Name (required)

Your City (required)

Your State (required)

Your ZIP Code (required)

Your Personal Email (required)

Your Mobile Phone Number (required)(no dashes)

Your ENA Member Number (required)

Your ENA Member Expiration (required)

Year of Initial ENA Membership (required)

Your Texas Chapter (required)

Years of Emergency Nursing Experience (required)

What other financial support will you receive for this conference? (required)

State CouncilChapterEmployerOther ScholarshipSelfOther

Submit a short statement of financial need for a scholarship. (required)

Upload a completed W9 form (3MB file size limit)(required) - Download Form W9

EN 23 Applicants Only

Are you a General Assembly Delegate?

DelegateAlternate DelegateNot Attending GA

Are you EN23 Faculty?

YesNo

What is your Registration Preference?

In-personVirtualBoth

Have you Attended a previous ENA National Conference?

YesNo

Submit a Short Statement of Professional Goals for Attendance at EN 23. Include statements regarding: how will you use what you have learned and how it will affect your nursing practice.

Submit a Short Statement of Educational Goals for Attendance at EN 23

Other CE Conference Applicants Only

CE Conference Title

CE Conference Sponsor

CE Conference Location

CE Conference Date(s)

CE Conference

ANCCTNCCCENENPCCPENTCRNOther

Submit a Short Statement of Professional Goals Related to this Conference. Include statements regarding: how you will use what you have learned and how it will affect your nursing practice.

Submit a Short Statement of Educational Goals Related to this Conference

Upload a Conference Brochure (3MB file size limit)

I agree to the following upon acceptance of Texas ENA scholarship funds:

Monies granted shall not exceed the amount spent on the conference. The amount awarded will be determined based on submitted registration receipt.

Initial: (required)

I have reviewed this application and to the best of my knowledge the information submitted is accurate. It is understood the decisions as to whether any application qualifies me for approved funding rests solely and exclusively on the recommendations of the Texas Scholarship Committee, and their decision is final.

Initial: (required)

I understand that upon receipt of a synopsis (~100 words) of my education experience (e.g., favorite topic/content/speaker) to the Texas Newsrunner for publication, scholarship funds will be dispersed.

Initial: (required)

Signature (required)

Date (required)

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