Executive Doctoral Program - Confirmation FormCongratulations! Your application for tuition assistance from the Kaiser Permanente (KP) Nurse Scholars Academy has been reviewed and conditionally approved for the Executive Doctoral program. Follow the instructions below to confirm your participation in the Executive Doctoral program. Confirm your name and NUID Provide your KP email address. Confirm and check off each of the program requirements. Sign and submit the form. Applicant InformationNUID*Name* First Last KP Email Address* Program Requirements Confirmation1. KP Nurse Scholars are expected to apply learnings to KP to improve professional practice, patient outcomes, and the delivery of high quality and affordable care for our members.* I Agree 2. We are honored to invest in your future and do so with the expectation that you will commit to continued service at KP for up to two years following your graduation.* I Agree 3. The Executive Doctoral program is funded by NCAL KFH/HP. If you leave the organization, or transfer to another KP entity or region, you may be ineligible for future tuition assistance.* I Agree 4. I understand that travel, lodging, books, and fees (other than tuition) are my responsibility* I Agree 5. I confirm my acceptance of the tuition assistance.*I AgreeI DeclineAcademic Institution Application StatusHave you been accepted into your program by the academic institution?*YesNoSignatureYour Signature*Use your finger or stylus (phone or tablet) or your mouse (PC or Mac) to sign in the space below.