GNCCARN Scholarship Request Form

     Directions:
  1. Request for scholarship funds must be received at least three weeks in advance of the conference.
  2. Print and Complete this Scholarship Request Form.
  3. Write a brief paragraph stating how this grant will enhance your professional development and contribute to your 
    career in Rehabilitation Nursing.
  4. Describe how you will share information learned with other rehabilitation nurses.
  5. Send three copies of the Scholarship Request Form to the Scholarship Chairperson: 

    Beth Hubbartt
    262 Lakeview Road
    Mocksville, NC  27028

Name:                              

Date:             
Home Address:                  Home Phone: 
School Enrolled:
Work Address:                   Work Phone:  
ARN Membership No: 
GNCCARN Activities within the past year:
Conference Name: Date(s): 
Anticipated Expenses to be Reimbursed -- not to exceed $100.00: (select one)
  Registration:  (Member or Student)
  Hotel: (Members only)
  Travel: (Members only)
Note: It is at the discretion of the GNCCARN Board & Education Committee to determine allocation of funds 
based on the budget for each year.
For Completion by GNCCARN:
Date Received: ______________     Previous Scholarship: __________
Amount: ___________________   Approved: __________   Not Approved: _________
Reason Not Approved: ___________________________________________________
Signature/Title: _________________________________________________________
Applicant Notified: _______________________________________________________
Check Number: ______________ Date: ___________