AgriSafe Nurse Scholar Program Scholarship Application

Full and Partial Scholarship Opportunities

Thank you for your interest in the AgriSafe Nurse Scholar Program. Applications will be reviewed on a rolling basis and applicants will receive a response within 5 business days from when the application was received.

Applicants granted a scholarship will receive a coupon code to use on registration, so please do not register for the course until you have received your coupon code.

Thank you to our generous sponsors CHS, Bayer, and Kroger for supporting the AgriSafe Nurse Scholar Program.

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* 1. Contact Information:

First Name:

Last Name:

Email Address:

Mobile Phone:

Work Phone:

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* 2. Mailing Address:

Street Address:

City:

State:

Zip Code:

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* 3. Work Information:

Employeer:

Job Title:

State of Nursing Licensure:

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* 4. Which best describes your employer? select all that apply.

Academia

FQHC

Government agency

For profit organization/hospital

Nonprofit organization

Nonprofit hospital

Private practice

Rural health clinic

School

Other (please specify)

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* 5. Please list the state(s) and counties where patients are impacted by your work (this can be defined as your service area). You may list more than one state/counties

State(s)

Counties

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* 6. Type of Nursing Practice:

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* 7. Level of Education:

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* 8. Briefly describe your experience in rural healthcare:

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* 9. What is your reason for wanting to participate in the Nurse Scholar program?

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* 10. Describe your plan for implementing change in your work environment, patient care, or community as a result of your participation in the Nurse Scholar program.