Massachusetts Society of PeriAnesthesia Nurses
Scholarship Application
Date______________ ASPAN Membership# _________________Phone____________
Street Address_______________________________________________
Town/City__________________________State___________Zip Code__________
Categories:
a. Money toward CPAN/CAPA Certification exam fee
b. Money toward CPAN/CAPA Recertification fee
c. Money toward pursuing advanced degree BSN/MS
d. Money toward a future MASPAN Seminar
e. Money toward an ASPAN Seminar
f. Money toward an ASPAN Workshop
g. Money toward ASPAN National Conference
Read Directions carefully and completely!
1. Documentation must be included for EACH activity (copy of cards, attendance, contact hours, letters from
Committee Chairperson).
2. Only activities earned within two years of the application date will be considered.
3. Applicants must be an active member of ASPAN/MASPAN for 2 years prior to the application date.
4. The application will only be processed if appropriate documentation is submitted with the application.
5. Each application is evaluated by the Board of Directors and given due consideration and is dependent upon fund
availability.
6. Scholarship recipients must submit a brief article to the MASPAN Newsletter Mayflower within 60 days after
receiving the award.
Activity
CPAN Certification #______________________________________________________________
CAPA Certification #______________________________________________________________
Recruited new ASPAN/MASPAN member ______________________________________________
MASPAN Officer (President, V. Pres, Secretary, Treasurer ________________________________
MASPAN Committee member _______________________________________________________
Attendance: MASPAN Seminar _____________________________________________________
Attendance: ASPAN Seminar/Workshop ______________________________________________
Attendance: ASPAN National Conference _____________________________________________
Speaker at ASPAN/MASPAN Seminar _________________________________________________
Recruit Vendor for MASPAN Seminar _________________________________________________
Contribute gift basket for fundraising _________________________________________________
Panel Member for MASPAN Seminar__________________________________________________
Publish article for MASPAN Mayflower_________________________________________________
Publish article for Breathline ________________________________________________________
Publish article for JoPAN or other Nursing Magazine ______________________________________
If you feel you have significantly contributed to the specialty of PeriAnesthesia Nursing in an area not addressed,
please submit your achievements (with written documentation/verification for consideration as part of your application.
Send to:
Ellen E. Sullivan, Chairperson Scholarship
137 Tiffany Road
Norwell, Ma. 02061
Phone 781-826-0258