Scholarship Application Form - DC Conferences

Scholarship Application FormAustralian Pain Society 33 rd Annual Scientific Meeting13 – 16 April, 2014Hotel Grand Chancellor, Hobart, TASMANIAPersonalised Pain Management: Search for the Holy GrailThe Pain Interest Group - Nursing Issues (PIGNI) is pleased to provide financial support to assist PIGNImembers in attending conferences or professional development days relevant to the pain managementspeciality.The Australian Pain Society Annual Scientific Meeting is an excellent opportunity for a PIGNI member toexpand their knowledge of pain and to network with other health professionals who have an interest inpain management. This Scholarship will be awarded to one successful applicant only and will include earlybird registration and $500 towards travelling and accommodation expenses.To be eligible, the applicant must be a financial member of PIGNI and provide information as detailed inthis application form. The successful applicant will be required to write a report for inclusion in the PIGNInewsletter. Please complete the following details and submit this form, along with your CV to the PIGNIsecretary via email Lbeeston@nsccahs.health.nsw.gov.au or to address: Lee Beeston, Co-ordinator AdaptPain Management Programme, Pain Management and Research Centre, Royal North Shore Hospital, StLeonards, NSW 2065, ph.02 94631510.CLOSE DATE: November 8, 2013Name:Email address:Contact Phone:APHRA registration number:Hospital / University:Position:PIGNI membership: (essential)Please complete the following information over the page.

This may be submitted typed as a separate document.Describe the relevance of the Australian Pain Society Annual Scientific Meeting, and how yourattendance is expected to contribute to your own nursing practice and/or place of employment.(Approximately 500 words)I am aware that the Scholarship covers the cost of an EARLY BIRD REGISTRATION for the Australian Pain SocietyAnnual Scientific Meeting 13-16 April 2014 in Hobart, TASMAINIA (worth estimate $920) and $500 towardsaccommodation or travel expenses for the meeting. PIGNI will reimburse these expenses upon receipt of invoices.The scholarship is not transferrable.Signature: __________________________ Name: __________________________ Date: ____________