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PEG BRIDGES SCHOLARSHIP

Scholarship Application Form

Personal Information

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Phone (Home/Cell)

Phone (Work)

Current Position

Department

Facility/Site Location

In this position since

Month and Year

Employment Status

Full Time Part Time Casual

Checkbox

RN LPN

Other:

FUNDING REQUEST

Are you applying for funding for this program from elsewhere?

Yes No

If yes, what is the maximum amount you would expect to receive from other sources? CA$

Degree/Certificate/Diploma Program Information

Name of Institution**

** Certificate of registration is Required

Please Attach Certificate of Registration Here

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City and Country

Name of Program

Start Date

Month and Year

Completion Date

Month and Year

Enrollment Status

Full Time Part Time

Tuition Fee* CA$

Awards will be considered for up to half the tuition costs. A copy of the tuition receipt is required. If applying before acceptance in program this may be deferred.

Please Attach Copy of Tuition Fee Receipt Here

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BENEFIT OF PROGRAM

Please describe why you have chosen to attend this institution?

How will this degree benefit you in your current position?

Support for the application is required from either your manager or supervisor

A letter is required from your manager or supervisor. Please make sure that your manager or supervisor completes the online form "Manager or Supervisor Support" which can found at the bottom of our awards page: https://gvef.org/staff-education-awards-program/

The following information will be required:

- Please describe how you anticipate your employee's participation in this program benefits the care of the elderly clients?

- Does the education program in which your employee is enrolled align with the priorities of your clinical program?

- How will knowledge gained enable you to meet your program's priorities?

Please Check One of the Following Two Boxes Below and Sign and Date Your Application Form

I confirm that I have attended the institution described in this application.

Yes

I have provided copies of all requested documents. If this application is successful, I agree to the publication of my name as an award recipient at the discretion of the Greater Victoria Eldercare Foundation.

I confirm that I intend to attend the institution described in this application

Yes

I agree to the publication of my name as an award recipient at the discretion of the Greater Victoria Eldercare Foundation. I am aware that if I am granted an award that I must provide copies of all requested documents with 6 months of the completion of the degree program and/or course work.

Signature

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Date

Month\Day\Year