ࡱ> g `bjbj xqbxqb= bb8"}bN("""q|s|s|s|s|s|s|$||9"""@""|bb|'''"RbbRq|'"q|''So"vH>$| #^rF]||0}er~J~#JvvJJ-w0""'"""""||%2"""}""""J""""""""" B (: Section A Student Release (To be completed by Cohen Scholars Program student) Social Security Number: ____ ____ ____ - ___ ____ - ____ ____ ____ _____ Date of birth: _______/________/_______ Last name: First name: MI: ___ Address: City: State: Zip code: Student Email: __________________________ Telephone #: Name of nursing program: __________________________________________Total Credits of program: _________________ Race/Ethnicity: FORMCHECKBOX  Caucasian FORMCHECKBOX  African American FORMCHECKBOX  Hispanic FORMCHECKBOX  Asian FORMCHECKBOX  Other Award/Degree sought: (select one)  FORMCHECKBOX  Masters Degree  FORMCHECKBOX  Doctorate Degree  FORMCHECKBOX  Post-Graduate Certificate Concentration: (select one)  FORMCHECKBOX  Nurse Practitioner (specialty)________(Peds, FNP, etc.)  FORMCHECKBOX  DNP Executive/ Leadership  FORMCHECKBOX  PhD Nursing  FORMCHECKBOX  MS HSLM  FORMCHECKBOX  MS Education Concentration  FORMCHECKBOX  MS Leadership Concentration  FORMCHECKBOX  Other (describe) ____________________________________________ I understand that MHEC may request my transcript information directly from the sponsoring institution in addition to my student account financial records related to the tuition and fees provided by the NSP II Cohen Scholars Program. I give my consent and authorize the sponsoring institution to provide this information to MHEC on MHECs request. I also agree to furnish any information requested pertaining to the objects of this agreement by the Commission and further agree to provide documentary evidence of compliance with the requirements of the award to include the required completion of the NSP II Annual Faculty Award survey for program outcomes and evaluation purposes. ________________________________________________________________________ ______________________ Signature of Cohen Scholars Student Date Section B Institution and Sponsorship Information (To be completed by the Dean or Director of the Nursing Program of the sponsoring institution). Sponsoring Institution: _______________________________________________________________________________ Sponsoring Dean/Director/Department Head of Nursing Program: ____________________________________________ Dean/Director/Department Head Email: ______________________________________Telephone #: _______________ Faculty Mentor: ____________________________________________________________________________________ Faculty Mentor Email: ________________________________________________Telephone#: ___________________ Degree Program: ___________________________________________________________________________________ The # of credit hours in Education/Curriculum & Instruction to be completed: __________________________________ Students Expected Graduation Date: ___________________________________________________________________ Institution where student currently works or one expected to hire the sponsored student, if known: _______________________ (Section B cont.) Section B Institution and Sponsorship Information (cont.) Our institution is sponsoring the above named applicant for the Cohen Scholars Program. In doing so, we agree to:  FORMCHECKBOX  provide mentors for the student and incorporate the student into our campus faculty culture,  FORMCHECKBOX  provide career counseling and assistance with placement as a faculty member at our institution or another nursing school in the State,  FORMCHECKBOX  provide a written mentoring plan with annual progress reports by the faculty mentor to include plan of study, progress, activities, meetings, expected graduation and faculty development (see pg. 3-6) and  FORMCHECKBOX  provide to NSP II, on request, all of the applicants transcript information and billing information. Signature of Dean/Director of Nursing Program: ___________________________________Date: ____________________ Section C Personalized Mentoring Plan (To be completed by students Faculty Mentor) Educators are encouraged to establish networks of mentors for development of long-term partnerships for shared growth and development. The mentoring relationship, initiated by this written contract, officially lasts until the end of the graduate nursing program and beginning of a new career as nursing faculty and beyond if indicated. The NSP II Cohen Scholars Program provides funding for the development of new nurse faculty. Institutions may sponsor selected students who indicate an interest in becoming nursing faculty at the sponsoring institution or another nursing school/program in Maryland. All sponsored students must sign a service obligation form, committing to service as a nursing faculty member at a Maryland institution or hospital education department, in order to obtain these educational funds and repay these funds with interest if they do not complete their program of study or do not complete their service as nursing educators. Please provide a brief description of the mentoring plan for the student recipient of the Cohen Scholars Program. The personalized mentoring plan MUST include the following or it will NOT be accepted (check (") each item below):  FORMCHECKBOX  Transcript review indicated 3.25 GPA each semester _________ current GPA  FORMCHECKBOX  The student s plan of study/course list with final degree to be awarded and length of time required to complete  FORMCHECKBOX  Plan of study includes a minimum of 9 semester hours of core education coursework, including a teaching practicum or TA  FORMCHECKBOX  Outline of mentoring using the approved Cohen Scholars Mentor form (For example, include personalization with the number and types of planned meetings, faculty shadowing and teaching experiences, etc.) Please attach a copy of the students signed personalized mentoring plan to this completed form. By signing this form, we acknowledge that the attached personalized mentoring plan is complete. We also certify that on an annual basis, the sponsoring institution will provide an update to this plan for the student including (1) progress that has been made in following the plan and (2) advise of any changes that have been made. If updated information is not provided by 8/31 each year, it is understood that the scholarship may be cancelled. Signature of Graduate Nursing Student: ___________________________________________________Date: _________ Signature of Faculty Mentor: ____________________________________________________________Date: ________ Last name: First name: _____ MI: _____ Address: __________________________________________________________________________ City: State: Zip code: _______________________ Student Email: ___________________________________Phone #: __________________________ School: ___________________________________________________________________________ Program: _________________________________________________________________________ School Address: _____________________________________________________________________ Advisor/mentor Name: _______________________________________________________________ Advisor/mentor Email: ___________________________________Phone #: ____________________ PROPOSED PLAN OF STUDY: * attach plan of study and note changes. Note semester of education core. Summer First sessionSecond sessionFall First sessionSecond sessionWinter First sessionSecond sessionSpring First sessionSecond sessionSummer First sessionSecond sessionFall First sessionSecond sessionWinter First sessionSecond sessionSpring First sessionSecond session MENTORING PLAN: Mentorship will provide a rich experience that introduces beginning teachers to experience the world of nursing education. (Mentor/Advisor and Student initial each requirement). _______1. Student will gain familiarity with the universitys mission, philosophy and programobjectives. Assigned reading/documents to be determined by mentor. _______ 2. Student will complete minimum of 9 semester hours in nurse educator core. Tuition is available for 12 semester hours. Another resource for clinical faculty (30 contact hours) is the Faculty Academy and Mentoring Initiative of Maryland (FAMI-MD)  HYPERLINK "https://nursesupport.org/nurse-support-program-ii/grants/statewide-initiatives/-faculty-academy-and-mentorship-initiative-of-maryland-fami-md-/" https://nursesupport.org/nurse-support-program-ii/grants/statewide-initiatives/-faculty-academy-and-mentorship-initiative-of-maryland-fami-md-/ _______ 3. Student will be provided opportunities each semester to shadow faculty membersin classroom,clinical or simulationsettings. This is to obtain a basic understanding ofcurriculumand courserequirements, class objectives and instructional techniques. _______4. Student will attend nursing faculty meeting and/or participate in the nurse educator career portal:  HYPERLINK "https://www.leadnursingforward.org/" leadnursingforward.org/. _______5. Student will participate in some form of synchronous collaboration system or Learning Management System or online place of gathering. May complete modules in: (Canvas or Blackboard Cohen Scholars Corner-topics such as: leadership, educator/faculty role, clinical simulation, resume building, job applications, interview skills, great faculty characteristics, how to continue in practice, etc.) specifically for Cohen Scholar recipients, addressing questions regarding faculty roles and challenges. Alternate plans to provide these gatherings need to be clearly identified. _______6. Student will participate with fellow Cohen Scholar recipients to discuss job opportunities job searches. (ex: NSP II Nurse Faculty Job Fair or the nurse educator career portal:  HYPERLINK "https://www.leadnursingforward.org/" leadnursingforward.org/ _______7. Student will complete poster, presentation or Journal Article Submission with assigned mentor. _______ 8. Student will attend the annual Maryland Action Coalition Conference (MDAC) and recommend at least one other Professional Development activity (ex: MCSRC-SEL Workshop, FAMI-MD, AACN faculty development, Sigma Theta Tau, Simulation workshop or another approved session) each year related to the topic of nursing education. _______ 9. Student will be advised on the Certified Nurse Educator (CNE) and/or professional development certification for the future. _______10. Student will maintain an annual professional membership. _______11. Student will talk monthly (by phone, computer or in person) with assigned mentor to review program progress, mentoring activities and faculty development opportunities. _______12. Student will complete financial literacy through online option or a formal finance course. Please identify which option is being completed. _______ 13. Student will advise faculty of where they are employed in a teaching role. Which school or hospital? _________________________________________________________________ Mentor to document employment Nurse Educator CompetencyRecommended Student Learning Experiences (During mentoring, module completion or academic coursework)Examples of competency attainmentStudent and Mentor initialsFacilitate learning Uses learning theories and educational strategies to develop a syllabus and lesson plan to promote active learning in classroom, clinical and simulated settings. Facilitate learner development and socializationIdentifies learner differences, assesses learner needs and learning styles; reflects these in planned learning experiences Uses strategies to socialize the learner to the role of the nurse educator. Use assessment and evaluation strategies Uses a variety of strategies to assess and evaluate student learning outcomes in classroom, online, clinical, and simulated settings Participate in curriculum design and evaluation of program outcomesGains familiarity with university and School of Nursing/clinical agency mission, philosophy and program objectives and how these elements guide curriculum/program development. Evaluates curriculum using SON evaluation plan 5. Function as change agent and leaderCompletes leadership module in Cohen Scholars Corner Writes short reflection of own leadership development6. Pursue Continuous Quality Improvements in the Nurse Educator Role Completes poster, presentation, or Journal Article submission related to nursing education  7. Engage in ScholarshipShadows faculty members in classroom, clinical, simulation or online settings to gain understanding of curriculum and course requirements, class objectives and instructional techniques. Acknowledge that scholarship is an integral component of the faculty role, and that teaching itself is a scholarly activity. 8. Function Within the Educational EnvironmentKnowledgeable about the educational environment within which they practice and recognize how political, institutional, social, and economic forces impact their role. Completes 9 credits of nurse educator core (list courses completed Completes 9 credits related to nursing education, 3 of which include the teaching practicum.  Makes a plan to become a certified nurse educator, clinical educator or professional development specialistReviews certification criteria and registration process; attends exam review session as appropriate.  Meets monthly with mentor Review progress and faculty development opportunities EXPECTED GRADUATION: Student plans to graduate in _____/_____ (MM/YY). By signing this form, we acknowledge that this personalized mentoring plan is complete. We also certify that on an annual basis, when requested by MHEC, the sponsoring institution will provide an update to this plan for the student including (1) progress that has been made in following the plan and (2) advise of any changes that have been made. If updated information is not provided when requested by MHEC it is understood that scholarship may be cancelled. Initial Review Signature: __________________________________________________________________________ Advisor/Mentor - Nursing Program Signature: _________________________________________________________________________ Student, Graduate Nursing Student Annual Update of Cohen Mentoring Form- May complete a new form annually with more recent information. Signature: __________________________________________________________________________ Advisor/Mentor - Nursing Program Signature: _________________________________________________________________________ Student, Graduate Nursing Student FOLLOW UP: _______ Graduation _______ Graduation date _______ Complete 9 semester hours in nurse educator core _______ Secures job in field for completion of service obligation Name of employer, position and contact person: ______________________________________________ _______________________________________________________________________________ OR _______ Scholarship is retroactively voided. Refer to MHEC for collection if faculty preparation requirements or service obligation is incomplete.      Cohen Scholars Program (ANEC) award  ?GOP  - 3 6 ? F G N O U [ f o u v w øtltlt^hChYm5CJ\aJhCCJaJhChp\CJaJhCh v7CJaJhChCJaJhChp\>*CJaJhChCCJaJhChYm>*CJaJhChYmCJaJhCh`UCJaJhChx5CJaJhCho5CJaJhChOQ5CJaJhChOQ5>*CJaJ"P  F G qojjgdya+$ D` @ `@ !#%`'@)a$gdp\($ D` @ `@ !#%`'@)a$ @@dgdOQ.$ D` @ `@ !#%`'@)dha$gdOQ     ( ) * 8 9 : K L M [ \ ] f g h v w x ~  ĹȭĢȭėȭČȭāȭvhhChFt}5CJ\aJhcMF5CJ\aJjhcMFUjbhcMFUjhcMFUjvhcMFUh|hcMFCJ\aJjhcMFUhcMFjhcMFUh|hcMFCJhC5CJ\aJhChjPq5CJ\aJhCh5CJ\aJ( ) L g  J K 7856gdFf @@$Ifgdl        ) ȼȼs_sSBS jhChFt}5CJUaJhChFt}5CJaJ&j+hCh 5CJUaJhCh 5CJaJ jhCh 5CJUaJhChW5CJaJhCh5CJaJ&jhChya5CJUaJhChya5CJaJ jhChya5CJUaJhCh5CJ\aJhC5CJ\aJhChFt}5CJ\aJ) * + J K Z [ e f h i w x y z   õϡϘτϵp۵bhChWx5CJ\aJ&jhChFt}5CJUaJ&jhChFt}5CJUaJhHq=5CJaJ&jhChFt}5CJUaJhChFt}5CJ\aJhChWx5CJaJhChFt}5CJaJ jhChFt}5CJUaJ&jhChFt}5CJUaJ!   % ( , - / 0 > ? @ [ _ g h v w x ϟϋznZzNhChHq=5CJaJ&j hChWx5CJUaJhChWx5CJaJ jhChWx5CJUaJ&je hChFt}5CJUaJ&jhChFt}5CJUaJhChWx5CJ\aJhChFt}5CJ\aJhChFt}5CJaJ jhChFt}5CJUaJ&jyhChFt}5CJUaJ #/<}78A{|~   V^tu󨜑znnnnnnn`nhChW56CJaJhChW5CJaJhChv5CJaJhChFt}CJaJhChFCJaJhChF>*CJaJhChF5CJaJhChjPq5CJaJhChi/5CJaJh5CJaJh5CJaJhq5CJaJh fh f5CJaJhCh5CJaJ% tuCD cdV{| hh^h`hgdIAh^hgdIAgdIAdgdcMFdgdWxgd-5  +IY>bd󮥜}ui}^}S}hChoCJaJhCh_E9CJaJhCh6>*CJaJhcMFCJaJhCh6CJaJhi/CJaJhCh f5CJaJh65CJaJhi/5CJaJhIA5CJaJh(5CJaJh(h(5>*CJaJh(hW5>*CJaJhi/5>*CJaJhChjPq5CJaJhChW5CJaJdestuwez{|}IKVW[\ǾDz𕍂sasVMh6CJaJh3NhoCJaJ#j= hChoCJUaJjhChoCJUaJhChOCJaJhIACJaJhChoCJaJ#j hCh_E9CJUaJhCh_E9CJ\aJhIACJ\aJhChoCJ\aJ#jQ hCh_E9CJUaJhCh_E9CJaJjhCh_E9CJUaJ|\]GH\]<N  x!y!!!#^gdIAh`hgdIAgdIA hh^h`hgdIAh^hgdIA\]^lmn%)DFHQT`ٴ󦘦qcScCcSchChjPq56CJPJaJhChjPq5>*CJPJaJhChjPq5CJPJaJhChya5CJPJaJh6Oy5CJPJaJhCho5CJPJaJhCh5CJPJaJhCh]5CJPJaJhChFt}CJaJhCJaJ#j hChoCJUaJhChoCJaJjhChoCJUaJhCho>*CJaJabL"X] :<LN󹩙~~n~`P@hChO56CJPJaJhCh56CJPJaJhChC5CJPJaJhChJ5>*CJPJaJhChJ5CJPJaJhChJCJPJaJhChr56CJPJaJhChJ56CJPJaJhChjPq56CJPJaJhChFt}6CJPJaJhChjPq5CJPJaJhChjPq6CJPJaJhChjPqCJPJaJNPlnpt  (*,0~    ȵxlx`Q?#j hChrCJUaJjhChrCJUaJhChCCJ\aJhChrCJ\aJhChJCJ\aJ#j hChJCJUaJjhChJCJUaJhChC56CJPJaJhChJCJaJhdDCJaJhChrCJaJ#j) hChCCJUaJhChCCJaJjhChCCJUaJ   $ Q !!!!!&!0!D!q!x!!!!!!!!!""Z"b"享{pdpdpXpXpXphChDZ6CJaJhChDZ5CJaJhChDZCJaJhIACJaJhChrCJaJ#j hChJCJUaJhChJCJaJjhChJCJUaJhChCCJ\aJhg2CJ\aJhHq=CJ\aJhChrCJ\aJhChJCJ\aJjhChrCJUaJ"b"&#C#_#v#z####$$r$s$t$|$$$$$$$$$$$$%% %&%)%2%L%N%U%[%\%%%%%%%%%&P&Q&Y&&&&&&&&&ƽ hS%h1 hj@h1hp3h1>* h1>*h1 hp3h1h15CJ aJ hIA5CJaJhChrOCJaJh6OyCJaJhChr6>*CJaJhChDZ6>*CJaJhChDZCJaJ8###$$$r$s$t$u$v$w$x$y$z${$|$$$ %%L%N%%%%%Q&R&gd1gdIAgdIAR&&&&'Y'Z'''''' $IfgdZ"gd1 &''''',';'@'X'Y'Z'['q'r''''''''''''''''(((('((()(9(:(;(B(Q(R(S(c(d(e(l({(|(}((((((((((((((((((((((ǼǼǼǼǼǼǼǼǼǼǼǼǴǼǴǼh1CJaJhpVh1CJaJhF0h1CJaJhg2CJaJhg2h -h1>*hF0h1>* hF0h1 hS%h1h1G'''''ZQQQ $IfgdZ"kd$$Ifl4CFo$`  t06    44 lapytZ"'''''ZQQQ $IfgdZ"kd$$Ifl4^Fo$   t06    44 lapytZ"''(((\SSS $IfgdZ"kd$$Ifl^Fo$  t06    44 lapytZ"((('(((\SSS $IfgdZ"kdl$$Ifl^Fo$  t06    44 lapytZ"(()(*(9(:(ZQQQ $IfgdZ"kd5$$Ifl4CFo$`  t06    44 lapytZ":(;(C(Q(R(ZQQQ $IfgdZ"kd$$Ifl4^Fo$   t06    44 lapytZ"R(S(T(c(d(\SSS $IfgdZ"kd$$Ifl^Fo$  t06    44 lapytZ"d(e(m({(|(\SSS $IfgdZ"kd$$Ifl^Fo$  t06    44 lapytZ"|(}(~(((ZQQQ $IfgdZ"kd[$$Ifl4^Fo$`  t06    44 lapytZ"(((((ZQQQ $IfgdZ"kd$$Ifl4CFo$   t06    44 lapytZ"(((((ZQQQ $IfgdZ"kd$$Ifl4^Fo$`  t06    44 lapytZ"(((((ZQQQ $IfgdZ"kd$$Ifl4CFo$   t06    44 lapytZ"(((((ZQQQ $IfgdZ"kdg$$Ifl4yFo$`  t06    44 lapytZ"(((((ZQQQ $IfgdZ"kd*$$Ifl4^Fo$   t06    44 lapytZ"((((( ) ) ) ))))))h*x******|+}+,,,,-xdUdHdhh0JCJaJhhB*CJaJph"""&jhhB*CJUaJph"""hhCJaJh&B*CJaJph"""hhg2B*CJaJph"""hh1B*CJaJph"""h&B*ph"""h= h1B*ph"""h= h1>*B*ph"""hnL>*B*ph"""h1 hS%h1hpVh1CJaJhF0h1CJaJhg2CJaJ((( ) )\SSS $IfgdZ"kd$$IflFo$  t06    44 lapytZ" ) ) ) )))x*z*,\WWJJJJJ -DM gd1gd1kd$$Ifl^Fo$  t06    44 lapytZ",,--x.z.0011?2A23344b4d45555)6*66gd1 -DM gdg2 -DM gd1---0-p-{----.+.,.].^.u.v.z.....&/0/0y00000001!1;1_1b111111111A2I2们们hwB*CJaJph"""hh![0JCJaJ&jhh![B*CJUaJph"""hh![B*CJaJph"""hhB*CJaJph"""hhg2B*CJaJph"""hh1CJaJhh1B*CJaJph"""h+>uB*CJaJph"""-I2J222222233334$4d4m455555555566'6(6*6M6O6[6l6᝴vôj^h2M/B*CJaJph"""h+>uB*CJaJph"""hB*CJaJph"""hWB*CJaJph"""hhHq=B*CJaJph"""hh1CJaJhHq=B*CJaJph"""hhg2B*CJaJph"""hhB*CJaJph"""hhB*CJaJph"""hh1B*CJaJph"""hhB*CJaJph"""!l6m6666:::: ;x;y;;;<<&<T<<<=== > >>?>>>> ??*?0???¸|obh*6h1CJPJaJh1h1CJPJaJh8| hgCJPJaJh8| h1CJaJh1CJPJaJhIf%hgCJPJaJh*6hgCJPJaJhgCJPJaJh*6htCJPJaJhIf%CJPJaJhcMFh1CJaJhhB*CJaJph"""hcMFB*CJaJph"""#666737@7P7$ i&`#$/Ifgd*6P7Q7e7<% & F $ i&`#$/Ifgd*6m$kd$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6e7f7 8 8 8$ i&`#$/Ifgd*6$ i&`#$/If^gd*6m$ 8 8=8<% & F $ i&`#$/Ifgd*6m$kdo$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6=888999$ i&`#$/Ifgd*69 929:# & F $ i&`#$/Ifgd*6m$kdQ$$Ifl\) 3I',   t 6` i0U-644 lap(yt*62939999$ i&`#$/Ifgd*6$ i&`#$/If^gd*6m$99:<% & F $ i&`#$/Ifgd*6m$kd7$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6::::::$ i&`#$/Ifgd*6::y;;;<***$ i&`#$/Ifgdgkd$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6;;;;;$ i&`#$/Ifgdg;<U<<&h$ i&`#$/If^hgdgkd$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6U<V<<<<$ i&`#$/Ifgdg<<<= ><***$ i&`#$/Ifgdgkd$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6 > > >>>(kd $$IflI\) 3I',   t 6` i0U-644 lap(yt*6$ i&`#$/Ifgdg>>>>>>$ i&`#$/Ifgdgh$ i&`#$/If^hgd1>> ?+?;?:((($ i&`#$/Ifgdgkd!$$IflI\) 3I',   t 6` i0U-644 lap(yt*6;?????*kd"$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6$ i&`#$/Ifgdg??? @(@@@@$ i&`#$/Ifgdg????@'@@@@@@@A7A9A:A>APACCCCCCDD&D}ufZJhg2hg25CJOJQJaJh1CJOJQJaJhh1CJOJQJaJhg2OJQJhg2h15OJQJhg2hg25OJQJh1OJQJ hQ>h1hcMFh1 hS%h1h -h1>* h f>* hcMF>*hhtCJPJaJhgCJPJaJh*6hgCJPJaJhgCJPJaJh {hgCJPJaJ@@@@@<***$ i&`#$/Ifgdgkdm#$$Ifl\) 3I',   t 6` i0U-644 lap(yt*6@@@@( dgdtkdO$$$Ifl`\) 3I',   t 6` i0U-644 lap(yt1$ i&`#$/Ifgdg@@@@@@8A9A:ACCCCnCCCDDDDDEWEEEEEEE"gdg2"gd1gd1&D~DDDEEEEEEEEEEEE6F7F_FhFFFFG9GAGoGrGȶpd]YUQUJU]FUFUhg2 hh(hcMFh(h1 hh1h&CJOJQJaJhhi/CJOJQJaJh1CJOJQJaJhi/CJOJQJaJhh1CJOJQJaJhg2h15CJOJQJaJ"hg2h15>*CJOJQJaJhhg2>*CJOJQJaJh1>*CJOJQJaJhhg2CJOJQJaJhg2CJOJQJaJEEEEE7F8FFFFFFGGGGGGGGGGG^gdOQgd?7gdIA( D` @ `@ !#%`'@)gd1"gd1rG~GGGGGGGGGGGGGGGGGGGGGGGH ()Ǿ~wume`[ShOQhOQ\ hdD\ hya\hOQh\hOQhya\U hOQ5\ h (5\hyahya6CJaJh v76CJaJho6CJaJhOQ6CJaJhC6CJaJh?6CJaJhya6CJaJ+jhyahya6CJUaJmHnHuh"jh"Uh1h15CJ aJ hh1hg2Nominee Information Form  Page  PAGE 6 of  NUMPAGES 6 Maryland Higher Education Commission Nurse Support Program (NSP II) 6 N. Liberty Street, 10th Floor Baltimore, MD 21201 (410) 767-3300; (800) 974-0203 TTY: (800) 735-2258 www.mhec.state.md.us  EMBED Word.Document.8 \s  G)+,tuvw&;<=>]^_gd`U$a$gd?7gd?7h`hgdi/  !0*gdSgdK $^a$gd`U$a$gdOQgdOQ)*+-QVW]^_`depqrstvw:;<º®º®ܚxnfhyaOJQJhOQCJOJQJhhyaCJH*OJQJhi/CJOJQJhyaCJOJQJh"jh!MhyaU\aJ*hW\mHnHu*h!Mhya\jh!MhyaU\aJ h!Mhyahhyah`Uhya5CJaJ%jhya5CJUaJmHnHu$<=>?YZ[\^_`h1h15CJ aJ h"j5%hyaUjUR hyaCJUVaJjhyaUhyahyaOJQJ _`gdIA21h:pWx/ =!"#$% `!wGCox!=H- qcHExYoG,E!HDJ}4iQHUgPnQ4N+%fvvfgo=~3޼=-͐(@UA=A7dm5og(e~G?߿,ԯй2װFM61n7:[gr?,[3"$1)+}G,蘆M͉agAV\؁n^F"EQ\F~rpб7h#  1:j.!<57W;Sbho/Z>kѹȾıʞڈyQۖCA,*3'䳧v/m52ҕ3G6|3.)py P*J6~ӛ9]/?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnoqrstuvwxyz{|}~Root Entry  F>$|@ Data p*WordDocument ObjectPool`^=$|>$|_1387180885 F`^=$|`^=$|Data 1TableCompObjrDd31 = 0  # Ab'Ѩ*SNJ\}D<nѨ*SNJ\}PNG  IHDR ;GsRGBPLTE333f3ffffff3f̙3fƭff3333f333333333f33333333f33f3ff3f3f3f3333f33̙33333f3333333f3333f3ffffff3f33ff3f3f3f3fff3ffffffffffff3ffff̙fff3fffffff3ffffff3f333f3333f3ffffff3f̙̙3̙f̙̙̙̙3f3f̙333f3̙333f3fff̙fff3f̙̙3f̙3f̙̥!fPP3333f3333f3ffffff3f̙3f3f| """)))999BBBMMMUUU___www3f𠠤|T pHYs u[IDATXGWQ0 7jzӽ TڑZѵ$K۩_ 30x6aGo?u^[UXO`0֩Qa^Vܹ5Ƹ–ݨ?!O6vf"xg+&UYky=*,R/}ίN4\o՜e;g-ݞO}6_S ݯ"e̞vΫdU*V) ?kZ5 pLG往(w<jn k ɽhN#kKAxw*yDgԙ Qk6eN˄au߀}"Z'[]h;$6qT]~ "Nq]nR:`SﺎV_7Ac$ڰ<$Pu/ޞn5디zXMTK`Fa΢4=-CK,Aof9 ^@]K0IENDB`^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH T`T Normal5$7$8$9DH$CJOJQJ_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List \$\ Envelope Address!@ &+D/^@ :%: Envelope Return>@@> Signature ^OJQJ4"4 Header  !4 24 Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  *@@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialY CG TimesTimes New RomanOCommercialScript-WPA$BCambria Math"h9"g xxr4YKHP)? *2!xx  LINDA Alice Legum  "#$%&(  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q Oh+'0  4@ ` l x @STATE GRADUATE NURSING SCHOLARSHIP AND LIVING EXPENSES GRANT jhendricObjInfo WordDocumentSummaryInformation( DocumentSummaryInformation8_ bjbj 0bb44444HHHH T H/````````$L4`````44``~~~` 4`4`~`~~~` j ~0/~t~4~``~`````t ```/````````````` :  h *jh *U.:p *F 2!"#$% Oh+'0l   ( 4 @LT\d LINDANormal Alice Legum27Microsoft Office Word@ @`Mw@ ,Q @Z՜.+,0 hp   MD Higher Education Commission  Titley%q`!xtV=ӯ49H- qcHFxYoGqB4$)RH{ 4A p*סϠpݢHi7VK).73;3o~ymoD= Z 24~!9]/PF,~ߟO_O;=_gh{|Ftj赎xb!23ȹڤK>QstUSI`Lz@m)e(-}M" 'RL:8vτ]_JjӪ|Ay7] h}tkf0͒FgDДp+ufxR@$&c_S*;i} Es"je7v[EѢHgQ_XK#?eg9sX4Tϑ?OZ U 5}XsU꫉)1Iշq-Z?Ghd߹o@G-bbX?<3<),ˡ > e)SԶʃ#T>ܿZSܮA$|NormalFord, Kimberly3Microsoft Office Word@ @ 8@m|@@ |3 q4 ՜.+,D՜.+,@ hp  ! MD Higher Education Commissiono= =STATE GRADUATE NURSING SCHOLARSHIP AND LIVING EXPENSES GRANT Title 8@ _PID_HLINKSAPi84$https://www.leadnursingforward.org/i81$https://www.leadnursingforward.org/k.https://nursesupport.org/nurse-support-program-ii/grants/statewide-initiatives/-faculty-academy-and-mentorship-initiative-of-maryland-fami-md-/   F Microsoft Word 97-2003 Document$s00p2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ nNormalCJ_HaJmH sH tH ::  Heading 1$@&5\HH  Heading 2$$@&^a$5\@@  Heading 3$$@&a$5\>>  Heading 4$@& 5CJ\DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4B@4  Body Text5\JPJ Body Text 2$ *$a$CJH @H 0Footer !5$7$8$9DH$aJT/"T Headline(5B*CJ<OJQJ_HmH phsH tH H2H 3x Balloon TextCJOJQJ^JaJ4OB4 eq02text CJOJQJ6U`Q6 :D Hyperlink >*B*ph@b@ AB List Paragraph ^B/qB nBody Text Char5CJ\aJ44 ?70Header  H$6/6 ?70 Header CharCJaJ2/2 /i0 Footer CharCJB' B ;Comment ReferenceCJaJ<< ; Comment TextCJaJ:: ;Comment Text Char@j@ ;Comment Subject5\F/F ;Comment Subject Char5\TST !OBody Text Indent 3 hx^hCJaJN/N OBody Text Indent 3 CharCJaJP`"P 1 No Spacing" CJOJQJ_HaJmH sH tH 3 tp Table Grid7:V#0#CJOJPJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< ??  )  d\N b"&(-I2l6?&DrG)<`$&()*+-.012347FJKL`dfjk |#R&'''(((:(R(d(|((((((( ),6P7e7 8=89299::;;U<< >>>;??@@@E%',/5689:;<=>?@ABCDEGHIMNOPQRSTUVWXYZ[\]^_abceil )9L\gw*hx /?gwd t |]mK[-=!>""O$$$'''?G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$XXX!:t ,2$GCox!=4@ h(  \  3 "?   A ?a1?.`!C`TC`T!!#" ?0(  B S  ?  )r3+*t=========>>??++=========>>??3t t  %gu+,12 !!))++++;;;<===>>>">#>$>=>L>P>z>>>>>>>>>>>>>????!?3?4?4?6?:?J?J?a?a?b?????t t  %gu+,12 !!))++;;;<==========>>>">#>$>=>L>O>z>>>>>>>>>>>>>????!?3?4?4?6?:?J?J?a?a?b????? ʑ"o PjH4|xmPo[jdJV(Us(na*&+7 K.l:/|t4h֩Up5BiW9V=ȣwA|t3Eam&Fn7SCM)_]M((ܧ@ N! Nc':OTI-nQ|tI1ZHR3)k]|t2_  a4|xNek1lufL{ZrɜniV{b80^8`0OJPJQJ^Jo(hH" ^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hHh88^8`.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L. hh^h`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(@xh8^8`. ^`5CJo(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`o(oh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h^`o(oh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L. ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(hhh^h`.88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`5CJo(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h^`. ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h ^`hH.^`.pL^p`L.@ ^@ `.^`.L^`L.^`.^`.PL^P`L. ^`OJQJo( ^`OJQJo(o   ^ `OJQJo(   ^ `OJQJo( xx^x`OJQJo(o HH^H`OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o   ^ `OJQJo(   ^ `OJQJo( xx^x`OJQJo(o HH^H`OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo(hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(@xh8^8`.^`o(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h^`CJo(.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.h^`o(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h^`. ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(^`o(.^`.pL^p`L.@ ^@ `.^`.L^`L.^`.^`.PL^P`L.hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`5CJo(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.hh^h`CJo(o ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`5CJo(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L. jH aD1lufUp5mPV=_]M K.a*&FiV{4[:/nQF! No ':O@ NI1ZwAs()k]&+Ne{ZrV(iW93E CM2_@="7AmiHB="f DideEsedFse"G="CHul /8                         B"        .        4                4                 Xx`                 B"        j(r        B"                                  S        B"        4        GB        4                                   B"        ӌw        B"                         &^:CD#r|L5FCyFEToi ,b I,3Mg' L ra le db 8| /]$'5xbJtG23N&})y`Dhr t#dDeeq"#" #rx#$d$If%5X'r'U{'N(n(g +z+,-t>./@/2M/MF0g2$3p3Z84R45*6:7 v7v7^k8xA9_E9w9~9,: ;8<JR<Pf<Hq=>>>bX)e"iek~e8f/irjtjYm;mn nDnjPqW7sEsms$tZAtFtbt+>B6w3ϳճw.+紥ٰ5/i|!Rѱ<e>p\6Y S7dDG{1O (I"3}3xE8YGQ\ {d?gFo2~ g1;OQ>LH)- lE.RvB:n;nhrya{&@ Qc eq^lr%Fw !:%AD)eTTnqg=(lFal\5^ ?iz;rO ![v-U+&&T&GMDbe|J]J^6?7t/.D"-\_aX~oO'0y4ZK9<ku )1=Z"EjJ=D]{?WyeO*hCxuL\CA fWx==@5=5=5=5=4$$$>?@@@@Unknown G.[x Times New Roman5Symbol3. .[x Arial7..{$ Calibri_ Missive SSiTimes New Roman5. .[`)TahomamSouvenir Light SSiGoudy Old Style?= .Cx Courier New;WingdingsA$BCambria Math"1hh''bw3 q4o3 q4o!4== 2QHP ?3x2! xx2 <STATE GRADUATE NURSING SCHOLARSHIP AND LIVING EXPENSES GRANTjhendricFord, Kimberly                           MSWordDocWord.Document.89q