WMREF Continuing Education Scholarship

WICHITA MEDICAL RESEARCH & EDUCATION FOUNDATION
3306 E Central, Wichita, Ks 67208 316-686-7172 316-687-0033 (fax) Application for Continuing Education Funding Please submit electronically to scholarship@wichitamedicalresearch.org
APPLICANT INFORMATION
Name:*

First NameLast Name
Day Phone:*
Format: (000) 000-0000.
Cell Phone:*
Format: (000) 000-0000.
Current address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Previous address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYMENT INFORMATION
Current employer:*
Department:*
Employer address:*
City:*
State:*
Position or Job Title:*
Conference Name*
#CEUs to be awarded*
Conference Location - City*
Conference Date:*

MonthDayYear
Date
Conference Registration Fee:*
Meals/Food
Funding from other sources:*
Airfare/Mileage
Other
Describe:
Hotel
Total Request:*
Email Address:*
example@example.com
Nurse:TherapistPharmacistOther
Specify if other:
Upload a scanned or electronic copy of the conference brochure. Certification and Degree Classes are Not Eligible for Funding.*

Cancelof
Please describe the impact on direct patient care you expect to derive from this conference:
How do you plan to disseminate the new information or skills learned during this training:
Signature of Applicant
Date

MonthDayYear
Date
Printed Name of Supervisor - Required
Signature of Supervisor:
Date:

MonthDayYear
Date
Copy of the Conference BrochureSupervisor's Signature and email
Should be Empty:

WICHITA MEDICAL RESEARCH & EDUCATION FOUNDATION