(Reg.

Charity 1057749)

NORMA N. GILL
FOUNDATION

ENTEROSTOMAL
THERAPY
NURSING EDUCATION
PROGRAMME
(ETNEP)
SCHOLARSHIP

Application Form
Revised November 2005
Norma N Gill Foundation - ETNEP

ENTEROSTOMAL THERAPY NURSING EDUCATION PROGRAMME (ETNEP)

SCHOLARSHIP

Information for Applicants - Please read before completing the form.

The maximum amount which may be awarded is $ 4000 US.
Preference will be given to applicants from developing countries.
Please allow at least three (3) months for your scholarship application to be processed.
Selection of candidates for the scholarship is non-discriminatory.

A committee member of the Norma N Gill Foundation may apply for a scholarship. Any committee
member who applies for a scholarship will stand down from the committee that considers his/her
application. In other circumstances, where a committee member has a conflict of interest, he or she will
stand down from the committee determining that particular scholarship application. If, in the opinion of
other committee members there is a potential conflict of interest if a member sits on the committee
determining a scholarship application, the committee member will stand down for that application only.

To be eligible for an ETNEP scholarship, you must :

1. Be an associate member of WCET. If you are not already a WCET member, please return the
completed membership form with payment. If you are in financial difficulties, please request an
application form for a Membership Scholarship.

2. Be a registered nurse with at least two years postgraduate experience, preferably in the surgical
field or a related community area.

3. Be working in an ET Nursing position or intending to do so after completion of the ETNEP.

4. Be accepted by an ETNEP which is recognized by the WCET. If participation in the program is

dependent on financial support, you may ask the school to hold your place on the program until you
have obtained the necessary funds. A letter showing that you have been accepted for the ETNEP
must be sent with the application form. No retrospective applications (after completion of the
ETNEP) will be accepted.

5. Obtain an official letter from your nursing director acknowledging support for your participation in
the ETNEP and assuring continued support for ET nursing in your place of work.

6. Complete the attached Scholarship Agreement form.

7. Try to obtain other financial assistance, as the amount of the NNGF Scholarship may not be
enough to cover all your expenses. Your application will be considered more favourably if you
have made the effort to seek financial assistance elsewhere. The written replies to your
requests must be sent with your application.

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Norma N Gill Foundation - ETNEP

8. Obtain written confirmation of each of your expected expenses (airfare, passport/visa fees,
accommodation, etc.) and send them with your application form (see question 19). No payment
will be made until these documents have been received.

When completing the application form, please type or print clearly. Return your completed application form
with the documents listed to:

World Council of Enterostomal Therapists

Central Office
Box 48099 DO NOT SEND BY COURIER
60 Dundas Street East
Mississauga, Ontario YOU MAY SEND BY PRIORITY
Canada L5A 1W4 OR REGISTERED MAIL

Telephone: 905 848 9400

Fax: 905 848 9413
e-mail: [email protected]

IMPORTANT
THIS APPLICATION WILL NOT BE PROCESSED UNLESS IT IS ACCOMPANIED
BY:
o Letter confirming acceptance for the ETNEP
o Official letter from your nursing director acknowledging support for your
participation in the ETNEP and continuing support afterwards
o Letters showing the results of your other applications for financial assistance
o Completed Scholarship Agreement form
o If you are not already a member of WCET, membership application form together
with payment.
o Official estimates of your expenses, such as airline tickets, visa/passport fees,
accommodation costs, etc.

**NOTE: All documents must be sent in English.

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Norma N Gill Foundation - ETNEP

ETNEP SCHOLARSHIP APPLICATION FORM

(Please type or print clearly)

1. Date : __________________________________________________________________

2. o Miss, o Mrs., o Ms, o Mr.

Last name :_________________________ First name : _________________________

3. Date of birth : ____________________________________________________________

4. Address for correspondence :________________________________________________

_______________________________________________________________________

_______________________________________________________________________

5. Email for correspondence : _________________________________________________

6. Telephone number (work) : __________________ (home) : _______________________

7. Fax number (work) : _______________________ (home) : _______________________

8. Main language : __________________________________________________________

9. Other languages (spoken / written) : __________________________________________

_______________________________________________________________________

10. Degree /diplomas

Degrees /diplomas Institutions Dates

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Norma N Gill Foundation - ETNEP

11. Present occupation and work position : ________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

12. Name and address of employer : _____________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

13. Name of the ETNEP which has confirmed acceptance : ___________________________

14. Name and address of your contact person at the ETNEP : _________________________

_______________________________________________________________________

_______________________________________________________________________

Email : _________________________________________________________________

Telephone number : ____________________ Fax number : _______________________

15. Dates of the ETNEP which you wish to attend :

From : _______________________________ To : _____________________________

16. Is there an ETNEP in your country which is recognized by the WCET? If so, please

explain why you are not taking this programme : ________________________________

_______________________________________________________________________

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Norma N Gill Foundation - ETNEP

17. Have you already received a membership scholarship from the Norma N Gill Foundation?

If so, for what year(s)? _____________________________________________________

If not, from whom did you receive information about the NNGF scholarships?

Commercial Source Name : Country : ________________

WCET Journal

ET Nurse (name): Country : _______________

ETNEP Director (name ) : Country : ________________

Other, Please specify name and address : _______________________________________

________________________________________________________________________

18. Other requests made for financial assistance :

SOURCE SPECIFY AMOUNT

CURRENCY (e.g. US$ or GB)
Employer
Hospital/University

Cancer society

ET nursing association
(local, national)
Ostomy association

Charity organisation
(eg. Lions, Rotary)
Industry
(specify)

Other (specify)

TOTAL FUNDS RECEIVED

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Norma N Gill Foundation - ETNEP

19. Details of expenses :

TOTAL EXPENSES AMOUNT

CURRENCY (e.g. US$ or GB)
Travel (economy class round trip)
- Air
- Rail
- Road

Passport / Visa fee

ETNEP tuition
Accomodation
Books

Other expenses (specify)

TOTAL EXPENSES
OTHER FINANCIAL ASSISTANCE OBTAINED (question 18) - ( )
TOTAL AMOUNT REQUESTED

20. Describe the need for ET nursing in your country (for example, the population of your country and
the number of ET nurses) : ________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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Norma N Gill Foundation - ETNEP

21. How great is the need for ET nursing in your place of work? (for example, the population

served by your institution or community, the distance away from you of the closest ET

nurse, the number of beds, the number of ostomy operations per year, the number of

wound and/or incontinence patients referred to you per year ) : _____________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

22. After completion of the ETNEP, how will you use the knowledge acquired, and how will

it enhance your ET nursing practice? __________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

23. After completion of the ETNEP, what percentage of your time will you be spending on ET

nursing? _________________________________________________________________

24. Describe your current and/or past involvement in WCET __________________________

________________________________________________________________________

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Norma N Gill Foundation - ETNEP

ETNEP SCHOLARSHIP AGREEMENT FORM

I, (Print Name in Full) __________________________________________________________

hereby agree to the following conditions if I am awarded an ETNEP scholarship:

a) In the event that I am unable to attend the ETNEP after receiving the NNGF ETNEP Award, all
money awarded to me will be returned to the Norma N. Gill Foundation.

b) I shall submit to the NNGF chairperson, within three (3) months of completing or participating in
the ETNEP, a written personal profile not exceeding 500 words and a clinical paper. The clinical
paper may be the paper written as part of the ETNEP.

c) I agree to my clinical paper being submitted for possible publication in the WCET Journal.

d) I agree to the NNGF paying all or part of the award directly to the ETNEP director and to the
airline. If I require funding for other expenses, I guarantee to send all receipts to the NNGF within
three (3) months of completing or participating in the ETNEP.

e) I intend to stay in my country after completion of the ETNEP. I shall submit to the NNGF
chairperson, one year after completion of the ETNEP, a written report not exceeding 500 words,
explaining how I have made use of my ET nursing training.

Signature: _______________________________________ Date: _____________________

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Norma N Gill Foundation - ETNEP

PAYMENT AUTHORIZATION DETAILS

With the exception of personal expenses, the WCET will pay all or part of the NNGF award directly to the
ETNEP.

Name of Student : ______________________________________________________________

The Scholarship award should be made payable to:

Tuition : ETNEP Name and address : ___________________________________________

___________________________________________________________

Amount : ___________________________________________________

Travel : Applicant ETNEP Amount : _________________________________

Airline

Accomodation : Applicant ETNEP Others (please specify) :

___________________________________________________________

Amount : ___________________________________________________

Other expenses (please give full details) :

Expense : _______________________________________ Amount : ____________________

Expense : _______________________________________ Amount : ____________________

My Country will accept a Bank Draft in US Dollars Yes No

in Pound Sterling Yes No
in Euros Yes No

My Country will accept a Bank Transfer in US Dollars Yes No

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Norma N Gill Foundation - ETNEP

Bank Draft to be ma de payable to:

Name: _______________________________________________________________________

Address : ____________________________________________________________________

____________________________________________________________________________

Bank Transfer details:

Name: _______________________________________________________________________

Bank : _______________________________________________________________________

Branch : _____________________________________________________________________

Address : _____________________________________________________________________

_____________________________________________________________________________

Sort Code : ___________________________________________________________________

Account Number : ______________________________________________________________

Account Name : ________________________________________________________________

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