2023 Special Scholarship Application

2024 Special Scholarship Registration Reimbursement Application

Fields with a * are required.
EN24 Conference Registration reimbursement is limited to applicants with three (3) years of continuous membership in ENA. Other CE Conference registration reimbursement requires one (1) year of membership in ENA.

Only one EN24 or other CE Conference scholarship will be awarded to a member per calendar year.
General Information

All applicants must complete this section.
Applying for (Check one)*

EN 24Other CE Conference
Full Name*

First NameLast Name
Your Credentials*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Personal E-mail*
example@example.com
Your Mobile Phone Number*
Your ENA Membership Number*
Your ENA Membership Expiration (If lifetime member, use 01/01/2099)*

MonthDayYear
Date
Year of Initial ENA Membership (If unsure, estimate)*
Your Texas Chapter*
Years of Emergency Nursing Experience*
Did You Receive any External Funding for this Conference Registration?*

YesNo
Submit a Short Statement of Financial Need for a Scholarship. (Not to exceed 100 word) *

0/100
Upload a Completed and Signed W9 Form (3MB file size limit) - Download Form W9*

Cancelof
Upload your Conference Registration Receipt (must include amount paid). *

Cancelof
EN 24 Applicants Only
Application deadline is Nov. 15, 2024 at noon.
EN24 Conference Registration fee reimbursement is limited to applicants with three (3) years of continuous membership in ENA.
Are You a General Assembly Delegate?

DelegateAlternate DelegateNot Attending GA
Are You EN 24 Faculty?

YesNo
What was Your Registration Category?

In-personVirtualBoth
Have You Attended a Previous ENA National Conference?

YesNo
Submit a Short Statement of Professional Goals for Attendance at EN 24. Include statements regarding: How you will use what you have learned and how it will affect your nursing practice. (Not to exceed 100 words)

0/100
Submit a Short Statement of Educational Goals for Attendance at EN 24. (Not to exceed 100 words)

0/100
Provide a Synopsis that Describes your Educational Experience while Attending this Conference (a favorite topic, content, speaker or take-away). (Not to exceed 100 words)

0/100
Other CE Conference Applicants Only
Other CE Conference reimbursement requires one (1) year of membership in ENA.
CE Conference Title
CE Conference Sponsor
CE Conference Location
CE Conference Date (Application deadlines are March 31, June 30, Sept. 30 and Nov. 15, 2024 at noon).
CE Conference

ANCC ApprovedTNCCCEN ReviewENPCCPEN ReviewTCRN ReviewOther
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. (Not to exceed 100 words)

0/100
Submit a Short Statement of Educational Goals Related to this Conference. (Not to exceed 100 words)

0/100
Provide a Synopsis that Describes your Educational Experience while Attending this Conference (a favorite topic, content, speaker or take-away). (Not to exceed 100 words)

0/100
Upload a Conference Brochure (3MB file size limit)

Cancelof
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 the submitted registration receipt.
Your Initials*
I have reviewed this application and to the best of my knowledge the information submitted is accurate. I understand the decision to approve funding rests solely and exclusively with the Texas ENA Scholarship Committee and their decision is final.
Your Initials*
I understand that upon receipt of my completed and signed W-9 form, my conference registration receipt and a synopsis (~100 words) of my education experience (e.g., favorite topic/content/speaker), my application will be considered. I understand that my synopsis may be published in the Texas ENA newsletter.
Your Initials*
Signature*
Date of Signature*

MonthDayYear
Date
Should be Empty:

2024 Special Scholarship Registration Reimbursement Application

General Information

EN 24 Applicants Only

Other CE Conference Applicants Only