EJS-VNF 2018 Application
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1 EJS-VNF 2018 Application 1. I am applying as a(n): * Nurse faculty Auditor 2. To which program site of the Visiting Nurse Faculty Program are you applying? * May - Toledo, Ohio May - Towson, MD June - Boston, MA June - Minneapolis, MN October - Birmingham, AL October - Phoenix, AZ November - New York, NY 3. Please share the following information: First Name: Last Name:
2 4. Please share the following information: * School of Nursing Affiliation: Primary Employer: Position/Title: Mailing Address: City/Town: Zip/Country Code: Country: Alternate Mobile Phone Number: State/Province: 5. Please share the following information (for deposit refund and stipend) Mailing Address Mailing Address 2 City State Zip Code
3 6. Please choose one or more to describe your ACADEMIC DEGREES: * PhD DNP EdD MPH MSN BSN AA Other - Please Specify 7. Please choose one or more to describe your CREDENTIALS: * RN APN ARNP CRNP FNP GNP ANP CNS N/A Other - Please Specifiy 8. Why are you interested in attending the Visiting Nurse Faculty Training Program? *
4 9. How did you hear about this program? * Colleague (EJS Scholar) Colleague (non alumni) Conference from EJS program PF newsletter PF PF website EJS Brochure Moving Day Allied Team in Training (ATTP) Other 10. Please upload your CV or resume here. When uploading, be sure to first click "browse." Most file types, including.doc and.pdf, are accepted. Note: only complete applications will be considered. Applications submitted without all required documents will be considered incomplete. * Browse...
5 11. Share the following information about your first reference, for someone who can comment on your interest and experience in Parkinson's. You will be asked to upload a letter from this reference on the next page. * Name: Relationship to applicant: Title: Institute: Phone Number: 12. Please attach your first letter of reference here. When uploading your letters of reference, be sure to first click "browse." Most file types, including.doc and.pdf, are accepted. * Browse...
6 13. Share the following information about your second reference, for someone who can comment on your interest and experience in Parkinson's. You will be asked to upload a letter from this reference on the next page. * Name: Relationship to applicant: Title: Institute: Phone Number: 14. Please attach your second letter of reference here. When uploading your letters of reference, be sure to first click "browse." Most file types, including.doc and.pdf, are accepted. * Browse...
7 15. After review and acceptance of my application, I agree to send a deposit made payable to the Parkinson's Foundation ($200 refundable deposit for nurse faculty participants/$150 non-refundable fee for auditors) to: Parkinson's Foundation EJS-VNF Program at PF 1359 Broadway, Suite 1509 New York, NY ATTN: Lisa Hoffman In MEMO please write: "Deposit EJS-VNF" and the location of your training. PLEASE NOTE: The deposit will hold a space for you in the program.you will not be asked to mail in your deposit until AFTER acceptance by the National Director. Your deposit check will be held and mailed back to you after the Program. Please send a self addressed stamped envelope for your returned deposit check. Should you not attend the program, your deposit will be forfeited. No refunds will be given if a cancellation is made less than 45 days of program date. * Yes No No. I have been given permission to audit the course and waive the fee. Photography and Video Consent Form
8 16. I hereby grant full permission to the Parkinson s Foundation, to use my photograph, name, city and state, as well as video or audio recordings of me, in any publication or advertising materials (printed or electronic). I agree that the Parkinson s Foundation, may use such photographs or recordings of me with or without my name and for any lawful purpose in any format, including on PF s website and in PF s publications or presentations, such as newsletters, brochures, fundraising appeals, public service announcements, grant proposals, reports, awards, thank-you cards, displays, mailings and invitations. I agree that PF may keep copies of images or recordings of me, and may archive them on CD or in other electronic forms, so that they can be used to support our mission. * Yes, I agree. No, I do not. Communications/ PR Permission 17. Should you be accepted into the program, we would like to reach out to the Communication/PR office at your university to highlight your acceptance and involvement in this prestigious program. Please indicate if this is something you would be interested in having us contact you about. Yes, should I be accepted into the program, I would be pleased to work with you to share news of my acceptance and involvement in the program highlighted in the University news. No, I would prefer that you not contact my University about my acceptance.
Sample Application. 1. I am applying as a(n): Nurse faculty Auditor
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