Date of Application

First Name (required)

Last Name (required)

Credentials

WOCN Member #

Rocky Mountain region designation required

Street Address

StateCOAZWYUTNM

Zip Code

Phone

Alternate Phone

Email

Alternate Email

Employer

Job Title

Employer Phone #

Supervisor

Please list any WOCN conferences you have attended in the past 3 years

Will your employer assist you with conference registration, travel and/or housing ??YesNo

If so, indicate the amount your employer will assist:

Have you received financial assistance from the RMR in the last 3 years?YesNo

If yes, date:

If awarded a scholarship, you will be required to donate time to the RMR within the year of the award
Please indicate how you would donate your time:

Regional Conference Planning CommitteeNational Conference Regional Booth PlanningSubmit an article for the RMR Newsletter or WebsiteMembership Committee

*Other ideas are encouraged and should be submitted to the Scholarship Committee for consideration.

Describe how attending this event will impact your WOCN practice:

Describe your plan for sharing the knowledge gained from this experience with your peers:

Please provide any other information you would like the RMR WOCN to be aware of when considering this application:

I have emailed 2 letters of reference from a Professional Colleague (WOCN preferred) or Supervisor to [email protected]

I hereby affirm that the information provided by me is true to the best of my knowledge, and I will notify the RMR WOCN of any changes to this information.

Signature

*The RMR reserves the right to audit any application for a period of up to one year from the date of any award.