This form is currently not available to submit new applications.Instructions The sponsorship through the Executive program is offered by invitation only and is only available at the time of offering. If you are invited to participate in this offering and you are interested in taking advantage of this opportunity, we ask that you follow this two-step application process: Nurse Scholars Academy Application - to be considered for the sponsorship Before applying, carefully review the information below. You will need the following to complete this application: Current Resume/CV (in Word or PDF format) A Word document version (or PDF) from your completed Talent Profile (to complete your Talent Profile and to create a Word document or PDF of it, go to MyHR or see the Talent Profile instructions attached to the original invitation email for additional help) A brief statement of purpose. Nurse Scholars Academy applicants must write a brief statement of purpose (minimum of 250 words) that describes their reason for pursuing the academic program and how they plan to support organizational goals as a result of this program. The statement should be written in a thoughtful and scholarly way - statement quality will be taken into consideration by the selection committee. Your direct supervisor's name, NUID, and KP email The Nurse Scholars Academy application must be completed in one sitting. The application cannot be saved, however it will not time out. Please assemble supporting documentation and retain the original invitation email to ensure you can come back to the application form when you are ready to apply. Reference Form: Applicants are responsible for notifying their direct supervisor to expect an email link from the Nurse Scholars Academy. The email provides the supervisor with a link to a reference form. The form will take approximately 5-10 minutes to complete and must be submitted by the supervisor in a timely manner to demonstrate support for the applicant. Application - to undergo the academic review and be accepted into the academic program Apply to the program by following their instructions. Please contact directly if you have any questions regarding their process. Send the Nurse Scholars Academy proof of acceptance from , in order to obtain the tuition sponsorship. -- Start of the Application Form -- NOTE: The sponsorship for the Executive program is offered by invitation only and is only available at the time of offering. If you were not specifically invited to participate in this program then this application form is not for you.Eligibility Pre-CheckIn order to be eligible for the Executive program you will need to be a KFH/HP NCAL non-represented benefited (20+ hours) registered nurse executive. This program is currently not available to employees from other regions or to employees from other entities (e.g. TPMG, Program Offices, etc.).Are you a KFH/HP NCAL non-represented benefited (20+ hours) registered nurse executive*I am currently a KFH/HP NCAL non-represented benefited (20+ hours) registered nurse executive.YesNoThe Executive program offered is currently only available to Kaiser Foundation Hospital (KFH) nurse executives in the Northern California (NCAL) region. You indicated that you do not fall within this category. Therefore, you are currently not eligible for the program offered here. We encourage you to explore other opportunities.Personal InformationName* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Preferred Phone Number*Alternate Phone NumberKP Email Address* Enter Email Confirm Email Personal Email Address Enter Email Confirm Email Employment InformationNUID*This is the same as your windows logon or your MyHR logon. One letter, followed by six numbers.Current Position/Job Title*(e.g. Chief Nurse Executive, etc.)Location/Facility*(e.g. Oakland Medical Center)Department/Unit*(e.g. Nursing Administration)Time in Current Role*YearsPlease enter a number less than or equal to 65.Time in Current Role*MonthsPlease enter a number less than or equal to 12.Overall Time at Kaiser Permanente*YearsPlease enter a number less than or equal to 65.Overall Time at Kaiser Permanente*MonthsPlease enter a number less than or equal to 12.Indicate Highest Level of Education Received*ADNDiploma: NursingBS/BA: NursingBS/BA: OtherMaster's Degree: NursingMaster's Degree: OtherJoint Master's (MSN & Other)DNPPhD: NursingPhD: OtherDoctorate: OtherIf 'Other', please specify*Direct Supervisor InformationYour direct supervisor will be sent a reference form based on the information you provide below. Make sure the information you provide is correct to avoid delays in the application process.Supervisor NUID*Supervisor Name* First Last Supervisor KP Email Address* Supervisor Phone Number*Program InformationSchool/Institution Name*School/Institution Website Address* Degree to be Awarded*If applicable, also provide the sub-specialty of the degree/programStart Date*If you don't remember the exact day, please select first day of the month in which you start(ed) Date Format: MM slash DD slash YYYY Expected Graduation Date*If you don't know the exact day, please select first day of the month in which you are expecting to graduate Date Format: MM slash DD slash YYYY Required DocumentationRésumé/CV*Add your current professional résumé/CV.Accepted file types: pdf, doc, docx.Talent Profile*Talent Profile printout (electronic Word or PDF document). To create or update your Talent Profile and to print out a copy of your profile as a Word or PDF document, go to MyHR (login required). You can find a tool here to help you with creating/updating your Talent Profile and printing it.Accepted file types: pdf, doc, docx.Brief Statement of Purpose*Nurse Scholars Academy applicants must write a brief statement of purpose (minimum of 250 words) that describes their reason for pursuing a doctoral degree in nursing and how they plan to support organizational goals as a result of this program. The statement should be written in a thoughtful and scholarly way - statement quality will be taken into consideration by the selection committee.AttestationI have accurately completed this application and provided the documents required, and have read the FAQs for this program and understand the requirements.*By checking this box and submitting this form, you are acknowledging that you have completed this application and provided the supporting documentation to the best of your abilities, and have read the FAQ for this program. I agree NOTE: Before you hit the Submit button check that all the required fields are filled out. If your application is complete you will see an onscreen confirmation message when you hit submit. You will also receive a confirmation email from firstname.lastname@example.org.