M. J. TOLEN SCHOLARSHIP FUND APPLICATION

Provide the following information on separate paper. Maximum 3 pages, double spaced. Provide 3 copies of application in application packet.

I. PERSONAL INFORMATION

(Non-discrimination Policy: Personal Information will not influence eligibility)

Name___________________________________________________________________

Address__________________________________________City_______________State/Zip______

Phone_______________________________________E-mail_______________________

Level of Education____________________________Current Occupation_____________________

II. COURSE OF STUDY INFORMATION

.....1. Course of Study Desired

.....2. Cost of Course

.....3. Length of time

..........a. Number of hours

..........b. Duration of course

.....4. Name of organization offering the course

.....5. Location of the course

.....6. Does the course offer educational credits or contact hours? If so, how many? Please describe.

.....7. List the name of the Approver and Provider, if applicable.

.....8. Does a professional association support this educational program? If yes, which one(s)?

III. APPLICATION QUESTIONS

.....1. Explain your interest in Complementary Therapies in End-of-Life Care (CTEOLC).

.....2. Have you studied other complementary therapies? If so, what, when, with whom?

.....3. Do you practice complementary therapies? If yes, do you practice them personally or professionally?

.....If professionally, do you do so in a private practice setting or under your employer?

.....If under your employer, what is the name of your employer?

  1. Do you currently work with End-of-Life Care? If yes, what type of setting (hospital, hospice, nursing home, private practice, volunteer)?

.....5. If you are employed and work in End-of-Life Care, what organization are you employed by?

.....If you do not currently practice CTEOLC, how do you plan to use Complementary Therapies in End-of-Life Care?

.....6. How will you use this course of study for which you are applying for funds?

.....7. What/who has influenced you to pursue this study?

.....8. What are your goals for taking this course?

IV. FUNDING SCHEDULE - CHOOSE CYCLE

1. Note which Cycle Number and year you are applying for (i.e. Cycle #1, 2004)

  1. The funding schedule offers 2 cycles per year with awards of 2 scholarships per cycle.
  2. Applicants can apply for up to $250 per course per cycle.
  3. Recipients may re-apply in future funding cycles.
  4. Scholarship funds will be distributed directly to the educator or institution.
  5. Scholarships will be utilized exclusively for coursework, excluding course materials.

Application Deadline Decision Notification Funding Granted

Cycle #1 November 1 December 1 January 1

Cycle #2 July 1 August 1 September 1

Applicant must send 3 copies of the application by the application deadline to:

MJT Scholarship Fund c/o Peaceful PassagesTM

214 Provincetown Road

Cherry Hill, NJ 08034