RMR WOCN National Conference Scholarship Application

    Date of Application
    First Name (required)
    Last Name (required)
    Credentials
    WOCN Member #

    Rocky Mountain region designation required

    Street Address
    State
    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.