FNE Scholarship Form
The Arizona Rural Women's Health Network (AzRWHN) was established to provide support and assistance to rural communities in addressing women’s health. In 2014 AzRWHN received a HRSA grant that included financial support for health care providers who want to offer or expand their ability to conduct forensic exams. As part of this, the Network has limited funding available to support nurses interested in obtaining the necessary training to conduct forensic exams for sexual assault victims. The funding can be used to pay for registration fees, travel and lodging for attending forensic exam trainings; however, after receiving this training the new acquired skills must be used to provide services in a rural Arizona community (as determined by the HRSA website).
Name:
Your answer
E-mail address:
Your answer
Healthcare facility currently working at:
Your answer
Where do you plan to conduct forensic exams? Please include a street address and city.
Your answer
What training do you plan to attend?
Include name, date, location, cost, and if outside Arizona, justification for why out-of-state travel is requested. Feel free to include a link to the training website, flyer, or any documentation about the training.
Your answer
Is there a registration deadline?
If so, please include it below.
Your answer
Travel request and cost to attend the training. Please detail by category (mileage/airfare, lodging, and per diem) and total cost.
Your answer
Please check the boxes below to indicate you accept the terms of our scholarship process.
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