Nurse Bursary Application Form

Information on the person applying for the Nurse Bursary

First name (required)

Last name (required)

Your Email (required)

Your Mobile Number (required)

Home address including postcode (required)

Gender (required)

Date of Birth (required)

Information about your employment

NMC pin number

Name of employer

Work address including department and postcode (required)

Job title (current employment)

Current employment start date

Band/Grade

Description of your present role

Questions about your funding request

What are you seeking to fund?

Brief summary of the course/conference/seminar and professional outcomes. Please state if this is a module of a longer course.

Start date (month and year)

Duration

Provide the contact details (name, address, phone and email) of the course, conference or seminar provider

Have you been awarded a place on the course, at the conference or seminar?
YesNo

Have you previously been awarded a bursary from Leukaemia Care or via the RCN Foundation?
YesNo

Please state how much you are applying for and how it breaks down i.e. are there travel costs as well as course costs?

How will this activity enhance your care of leukaemia patients?

How will you share your learning and development with your colleagues?

Application agreement

I confirm I have read the terms and conditions and agree to abide by them. I agree to provide a written report on the completion of the funded activity or to return funds on withdrawal from the funded activity.

On submitting this form, you will automatically be enrolled in receiving our email communications about our services, campaigns, volunteer opportunities, and how to get involved. You can unsubscribe at any time by calling 01905 755977 or by emailing communications@leukaemiacare.org.uk. We will never swap your details with other organisations or share them with other charities for marketing purposes.

Name:

Date: