Application for the Allison Zeppieri Fund Endowment

Transcription

1 Deadline is March 30, 2018 Application for the Allison Zeppieri Fund Endowment The Allison Zeppieri Fund was established in memory of Allison Zeppieri, a charming young woman with extraordinary potential who was deeply cherished by family and friends. To honour her life in perpetuity, the endowed fund will award an educational bursary to nurse(s) or allied health professional(s) of the mental health program at Mackenzie Health to support the advancement of their clinical skills and implementation of best practices of better outcomes and increased resilience for patients. The Zeppieri Family is dedicated to supporting exceptional, compassionate and patient-centered care of all mental health patients in their community. The Zeppieri family trusts their support of continuous and high-quality learning will both celebrate Allison s life and have a meaningful impact. Return the completed application, with attachments to Janet Belusic, Administrative Assistant, Professional Practice, c/o Mackenzie Health 10 Trench Street, Richmond Hill, Ontario L4C 4Z3

2 Allison Zeppieri Fund Endowment Eligibility Inter professional staff who support the Mental Health Programs and either full time or permanent part-time for a minimum of 1 year Criteria for Selection A brief Summary will be requested to document the following 3 perspectives: 1. The individuals specific interest in continued education focused on mental health 2. How the conference or program will assist with mental health practice to improve clinical skills and / or implement best practices 3. How the conference or program will benefit patient centered care The bursary will be awarded to four individuals, each to receive $500 each (consider 2 at $1,000 if low submission) How Can I Apply? Application forms are available from Janet Belusic, Administrative Assistant, Professional Practice, room 5914, B-wing or directly from Please review the information requested carefully and ensures you have completed the application form in its entirety. When is the deadline? A completed application form with attachments must be received by Janet Belusic by March 30, Allison Zeppieri Fund Endowment, 2018 Page 2 of 6

3 By Mail: Janet Belusic, Professional Practice, Room 5914, 10 Trench Street, Richmond Hill, Ontario, L4C 4Z3. Tel: ext or How Will Applications Be Reviewed? A Bursary Review Panel will be convened to review and award the bursary. All applicants will receive a response from the review panel and the successful recipient(s) will be presented with the award during Nursing Week celebrations. The bursary will be paid directly to the successful applicant upon submission of eligible receipts. Allison Zeppieri Fund Endowment, 2018 Page 3 of 6

4 Allison Zepierri Fund Endowment Personal Name: Department: Job Title: Work Extension: Home Telephone: Manager s/supervisor s Name: Employment Status: Full time Part time Date of Employment: Bursary Information 1. Please identify which course, conference or academic program you are requesting bursary support? Please attach accompanying brochure. 2. Please identify the name of institution/organization where program/course will be taken Allison Zeppieri Fund Endowment, 2018 Page 4 of 6

5 3. Please list the dates of the program/course and the amount of funding you are requesting. 4. How will this award help you develop your knowledge and skill? 5. How do you plan to share your learning with your colleagues? 6. Identify your specific interest in continued education focused on mental health? 7. How the conference or program will assist with mental health practice to improve clinical skills and/or implement best practices? 8. How the conference or program will benefit patient centred care? Allison Zeppieri Fund Endowment, 2018 Page 5 of 6

6 List expense details for Bursary Funds Currency: (e.g. Canadian dollars) Course/Registration Fee: Travel: Accommodation: G.S.T. Registration #: G.S.T. Total Request: Total Approved: Signature of Applicant Date Thank you for your application. Allison Zeppieri Fund Endowment, 2018 Page 6 of 6