Name____________________________________________________________________

Address_________________________________________________________________

City___________________________State_________________Zip:_______________

Phone: _____________________Fax:________________

E-mail address:__________________________

I am currently enrolled in the nursing program at _______________________

I am enrolled in a BSN______AD______Diploma nursing______________program.

Current year in school_____________Expected date of graduation___________

Requirements:

1. Complete this application and required essay.
2. A copy of your most recent semester transcript with grades and a cumulative
grade point average.
3. Letter of recommendation from a teacher, advisor, or counselor.
4. Completed application materials must be postmarked by April 5, 2012.
5. Your GPA must meet your schools criteria for academic eligibility.
6. Answer the following questions (no more than two double spaced pages)

1. Describe an experience which has impacted your decision to become a nurse or an experience you have
had during clinical which has reinforced your career choice.
2. Describe what area of nursing you are interested in and why.
3. Why should you be considered for this award? (Describe any community activities, honors, work experience,
awards, or positions of leadership received, if applicable)

Please mail completed materials to:

Southern Connecticut Black Nurses’ Association, Inc.
P.O. Box 8122
New Haven, Connecticut 06530

Recipients of the book awards will be notified by April 10, 2012. The awardees must be present to accept the awards at the 18th Annual SCBNA Scholarship and Awards Luncheon on Sunday, April 25, 2012 at Fantasia’s of North Haven, Connecticut.

For additional information contact Genice Nelson at (203)668-5420 or (203)688-8077 or e-mail genicescbna@gmail.com