JIM BEBB SCHOLARSHIP APPLICATION

JIM BEBB REIMBURSEMENT SCHOLARSHIP
In order to promote the educational pursuits of our members in LTC nursing, and support the facilities where they work, the Board of Directors and the Scholarship Committee are pleased to announce the awarding of up to ten (10) scholarships each year to qualified individuals who have furthered their education by becoming certified in an area that will positively impact their practice in Long Term Care Nursing. The maximum amount of each reimbursement scholarship will be $500. This reimbursement scholarship opportunity is available to Michigan NADONA licensed nurses, who have become certified in order to advance their nursing practice.
Criteria for scholarship application includes:
1. Submission of a completed application.
  1. The applicant’s information and essay section,
  2. TWO (2) REFERENCES,
  3. Proof of paid certification exam cost,
  4. Letter from your administrator,
  5. Copy of your certificate.
2. Applicants must provide proof of:
  1. Successful completion of a certification program within the preceding calendar year which can be utilized in the long-term care setting AND
  2. Proof of the amount paid specifically for the certification exam.
3. Reimbursement will cover the cost of the certification exam up to $500. Reimbursement will NOT COVER other associated costs, e.g., text books, review materials, tutoring sessions, travel, lodging, etc.
4. Submission of a letter from the facility Administrator (letter head required) acknowledging that the nursing facility / corporation has not (and will not) be reimbursing the applicant for cost of the certification exam.
5. MI/NADONA licensed nurse members may self-nominate.
6. Applicants must have current membership status. (Membership status will be verified. Accurate contact info is the applicant’s responsibility.)
7. Commitment to work in a Michigan Long Term Care Facility (nursing home) for at least one (1) year after completion of the certification.
8. All forms and additional documentation must be completely filled out and submitted by Sept. 1st. Applications will be accepted year round. Submitted complete applications will be reviewed after Sept. 1st each year.
9. If any of the required documents are missing or incomplete, your application will be disqualified. You will not be considered for the reimbursement scholarship award.
10. You will be notified of the status of your application by Oct. 1st.
11. Reimbursement Scholarship winners will be invited to the Annual Michigan NADONA/ LTC conference to receive their award. If the recipient is unable to attend the annual MI/NADONA conference to receive their award, the MI/NADONA Area coordinator will present the reimbursement scholarship award at a mutually agreeable later date.
APPLICANTS DETAILS
Applicant's Name

First NameLast Name
Applicant's Cell Phone
Please enter a valid phone number.
Applicant's Email
example@example.com
Personal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility of Employment
Type of Facility

SNFAL
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone Number
Please enter a valid phone number.
Length of Employment
Employment Start Date

MonthDayYear
Date
Employment End Date (select today if currently employed)

MonthDayYear
Date
Current Position
Certification Obtained:
Date Obtained:

MonthDayYear
Date
Accrediting Body:
Accrediting Body Phone Number:
Please enter a valid phone number.
Address of Accrediting Body

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Active Membership in Michigan Chapter NADONA?

YesNo
Number of Years of Membership (if applicable)
NOMINATING MEMBER'S DETAILS
Name of MI-NADONA Member Nominating Applicant for Consideration

First NameLast Name
Phone Number for Nominating Member
Please enter a valid phone number.
Email for Nominating Member
example@example.com
APPLICANT'S PERSONAL ESSAY
Please discuss the following: 1) Why you decided to obtain this certification. 2) How have you incorporated this advanced knowledge into your practice? 3) What positive impact have residents experienced because of your certification? 4) Describe your 5 year goals and your plan to achieve them. 5) Why should you be granted a reimbursement scholarship?
REFERENCES

All applicants must include TWO references, following the format required, in order to be considered for the scholarship.
Criteria for references:
1. Must include the full name, title, phone number, email, relationship to applicant of the referrer.
2. Applicant shall be rated Low, Average, High or No Opinion in the following categories
  1. Maturity
  2. Sensitivity to Residents
  3. Commitment
  4. Academic Abilities
  5. Ability to Communicate
  6. Leadership Skills
3. Referrer shall describe why they believe this applicant is a deserving candidate for the scholarship.
Upload Recommendation #1 Here

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Upload Recommendation #2 Here

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LETTER FROM ADMINISTRATOR

All applicants must include a letter from the facility Administrator (letter head required) acknowledging that the nursing facility / corporation has not (and will not) be reimbursing the applicant for cost of the certification exam.
Upload Letter From Administrator Here

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PROOF/RECEIPTS

Please provide proof of paid certification exam costs. Please provide proof of certificate issued.
Proof of Payment

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Proof of Certificate Issuance

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JIM BEBB REIMBURSEMENT SCHOLARSHIP

APPLICANTS DETAILS

NOMINATING MEMBER'S DETAILS

APPLICANT'S PERSONAL ESSAY

REFERENCES

LETTER FROM ADMINISTRATOR

PROOF/RECEIPTS