UMCORHealth APPLICATION FOR FUNDING

Parish Nurse, Health Advocate

Name                                                                                       E-Mail _____________________________

Phone (     )__________________________    Name of Church, City, State ____________________________________

Address (Street or PO Box) City Zip ________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Name of Course/seminar:_____________________________________________________________________________

Location __________________________________________________________________________________________

Date(s) and Sponsor _________________________________________________________________________________

Are you currently serving as a parish nurse or health advocate? (not required) If so briefly describe; if not briefly describe your future plan. 

How will attending this event enhance your leadership skills?

Itemize expenses that will be incurred along with other resources solicited and/or obtained with amounts requested:

EXPENSE ITEMS	ACTUAL -ANTICIPATED COSTS	OTHER RESOURCES AND FUNDING FROM YOUR CHURCH, DISTRICT, CONFERENCE	RESOURCES AND FUNDING YOU ARE PROVIDING PERSONALLY
Registration Fees(s)
Room
Meals
Travel
Resource Materials
Other
TOTALS

Total amount requested from UMCORHealth  $ ________________________________________

Signature of Applicant_____________________________________________________  Date___________________

Return this form to: UMCORHealth Parish Nurse Consultant

                              STH.RNR@DOOR.NET    or mail to: Sharon Hinton

                                                                                         2750 County Road 260

                                                                                          Floydada, TX 79235