Christian Science Nurse Education

The DOMINION FOUNDATION
for Christian Science Nursing, Inc.
Application for financial assistance with
Christian Science Nurse Education

All information you provide will be kept strictly confidential.

Applications are reviewed on a monthly basis by the Trustees. You will be notified shortly after the monthly meeting.
Are you interested in becoming a Christian Science nurse with an independent home care ministry? OR Are you an active Christian Science nurse pursuing independent home care ministries for Christian Scientists?*

YesNo
If you answered “Yes” to these questions, you may qualify for a grant. Please complete the application fully to enable us to process your request. All information you provide will be kept strictly confidential.
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number*

Monthly Income And Expenses

The more information you include, the more effectively The Dominion Foundation can consider your request for funding.
Monthly Income*
Assets*
Monthly Expenses *
Liabilities*

Additional Information
How many Christian Science home nursing cases have you had to date? *
How will this education help you be a better home care Christian Science nurse?*
Do you currently have transportation to make home Christian Science nursing calls?*

YesNo
If you are now affiliated with a Christian Science facility or residence, how will home Christian Science nursing cases affect your duties there?*
Please provide the name of at least one individual affiliated with Christian Science nursing whom we may contact regarding your work as a Christian Science nurse.
Name*

First NameLast Name
Title or affiliation with Christian Science nursing *
Phone Number*
By providing my signature below, I affirm that all information provided on this form is accurate.
Name

First NameLast Name
Date*

MonthDayYear
Date
Enter the message as it's shown*
Should be Empty:

Monthly Income And Expenses