Name
*
First Name
Last Name
Email Address
*
Phone Number
*
Manager is Aware of Application
*
Yes
No
If you are scheduled to work the day(s) of the event, approval for time off is required BEFORE your application is processed. Has your manager approved your time off?
*
Yes
No
If 'No', please describe
Manager Name
*
First Name
Last Name
Organization
*
Department
*
Address 1
*
Address 2
City
*
Job Title
*
Discipline
*
RN
RPN
PT
Other
If 'Other' please describe
Sector
*
Hyperacute (EMS, Emergency, ICU)
Acute
Rehabilitation
Prevention
Long-Term Care
Event Title
*
Event Start and End Dates
*
Location of Event
*
Description of Conference, Workshop, or Course
*
Registration, Conference or Tuition Fees
Projected Travel Fees
Projected Accommodation Cost
Projected Meals Cost
Total Amount Requested
*
Have you applied elsewhere for funds pertaining to this application?
Explain how the learning opportunity will benefit the following targeted audiences. Please include all that are applicable
*
Describe your specific plan to share your learning with each of the following targeted groups
*
Please identify the target audience of your learning plan by discipline and location
*
Please identify the target date for sharing your learning
*
Have you previously received funding from the Northwestern Ontario Regional Stroke Network Education Fund?
Yes
No
If ‘Yes’ please provide details, i.e. conference title, location, date and how you disseminated the learning
