Application Form for Continuing Education Activity Scholarship
*This application form is to be completed by the individual.

**Application submission entries are not able to be partially saved – you must complete the fields below and submit all at the same time.

***This form is to be completed for events occurring May 2018 – April 2019

Deadline April 6, 2018
Present street address:
City, State, ZIP:
Phone Number:
E-mail address:
Permanent resident or citizen of the United States?
State affiliate designated for the Academy of Nutrition and Dietetics (AND): *Note: Must designate Iowa as your AND affiliate to be considered for award.
Academic Record
Undergraduate College/University:
Major:
Graduation Date:
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Graduate College/University:
Major:
Graduation Date:
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Internship Name:
Completion Date:
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Dietetics-Related Honors, Volunteer Activities and Community Involvement
Describe participation in dietetics-related volunteer activities (Local, State and AND), meetings or other involvement. Include membership, leadership offices held and/or responsibilities. Add additional lines as needed.
Organization / Date / Responsibilities / Office / Position
Other Honors, Volunteer Activities and Community Involvement
List participation in any other activities (clubs, volunteer work, community organizations). Include membership, leadership offices held and/or responsibilities. Add additional lines as needed.
Organization / Date / Responsibilities / Office / Position
Employment
List employment in dietetics related fields.
Organization / Date / Responsibilities / Office / Position
Additional Funding
List any additional scholarships, awards, and education grants you have received or applied for to cover the expenses of this Continuing Education Activity.
Name of scholarship / grant / loan - Amount
List any previous scholarships or funding you have received from IAND.
List any additional scholarships, awards, and education grants you have received or applied for to cover the expenses of this Continuing Education Activity.
Name of scholarship / grant / loan - Amount
Continuing Education Activity
A continuing education activity may include, but is not limited to: CEU event/activity, Educational Conferences, Certification Exams, Research, Publishing, Educational Tools (food models).
Activity / Amount Requesting / Expected Date of Completion / Use of Funds
I understand that I will not receive the continuing education funds if I do not pass the examination or do not fulfill obligation to complete the Continuing Education Activity Report and participate in IAND slideshow (this is shown at the IAND annual meeting to make members aware of this funding opportunity). The activity must be complete within one year of application approval.
Submitted by:
Submitted on:
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Attachments for Iowa Academy of Nutrition and Dietetics Continuing Education Applications
Career Goals
Attach a typed one-page letter that identifies your immediate and long-term career goals and why this continuing education activity will help you reach these goals.

Letters of Reference
Attach two (2) letters of reference; one from your current supervisor and one additional from an individual that may speak to your unique strengths as a dietitian. Only two letters will be evaluated and scored during the application review process.

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