This application form only applies to the TPMG Choice Program. DO NOT use this application form for any other programs we may offer. Are You Ready? If you are not yet ready to submit your application with the requested supporting documentation, bookmark this page so you can come back to it when you are ready to apply. Deadline to Apply Application Cycle: April - October 31 Payout Cycle: December Application Process Before applying carefully review the information below. You cannot save this application, but it does not time out. The application needs to be completed in one sitting. You will need the following to complete this application: Proof of Acceptance in an accredited degree program Current Resume/CV Statement of Purpose Additional Information: What is the TPMG Choice Program? Nurse Scholars Academy is offering a new program with tuition assistance that will give TPMG NCAL non-represented, benefited registered nurses the flexibility to choose what accredited program and what school they would like to attend to get their BSN, or master's or doctoral degrees. Notify your direct supervisor that they will be receiving an email to complete a reference form. This tuition assistance is in addition to your annual tuition reimbursement benefit. We will deduct the maximum tuition reimbursement amount (currently $3,000) from your annual tuition needs. Annual funds received from the TPMG Choice program up to $2,250 will be non-taxable income. Funds received from the TPMG Choice program above $2,250 will be taxed. — Start of the Application Form —The application period is currently closed and we are not accepting new applications at this time.Eligibility Pre-CheckIn order to be eligible for the TPMG Choice program you will need to be a The Permanente Medical Group (TPMG) NCAL non-represented benefited (20+ hours) registered nurse. This program is currently not available to employees from other regions or to employees from other entities (e.g. KFH/HP, Program Offices, etc.).Are you a TPMG NCAL non-represented benefited (20+ hours) registered nurse*I am currently a The Permanente Medical Group (TPMG) NCAL non-represented benefited (20+ hours) registered nurse.YesNoThe TPMG Choice program is only available to TPMG NCAL non-represented, benefited registered nurses. You indicated that you do not fall within this category. Therefore, you are currently not eligible for the TPMG Choice program. We encourage you to explore other opportunities. For represented NCAL staff RN's you can also check out the RN-BSN program.Have you been accepted into your program and will you be taking courses this year?*I have been accepted into an accredited degree program and am currently or will be taking courses this year.YesNoAcceptance into your program is required before you can submit your application. Please come back once you have been accepted into your program.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. Assistant Nurse Manager, Nurse Manager, etc.)Location/Facility*(e.g. Oakland Med Center, Regional Offices, etc.)Department/Unit*(e.g. NICU, Quality, etc.)Time in Current Role*YearsPlease enter a number from 0 to 65.Time in Current Role*MonthsPlease enter a number from 0 to 12.Overall Time at Kaiser Permanente*YearsPlease enter a number from 0 to 65.Overall Time at Kaiser Permanente*MonthsPlease enter a number from 0 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 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/programSelect/Enter the accreditation body for your program*Commission on Collegiate Nursing Education (CCNE)Middle States Commission on Higher Education (MSCHE)New England Association of Schools and Colleges (NEASC)Northwest Commission on Colleges and Universities (NWCCU)Southern Association of Colleges and Schools (SACSC)WASC Senior College and University Commission (WSCUC)Western Association of Schools and Colleges (WASC)Start Date*If you don't remember the exact day, please select first day of the month in which you started 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 How Much Tuition are you Expecting to Pay This Year?*FYI, you will be expected to show proof of tuition paid in past year when applying for future funding supportPlease enter a number greater than or equal to 0.Required Documentation for the TPMG Choice ApplicationRésumé/CV*Add your current professional résumé/CV.Accepted file types: pdf, doc, docx.Provide a document showing that you were accepted into your program*Accepted file types: pdf, doc, docx.Have you previously received funding through the Nurse Scholars Academy Choice program.*You previously received tuition assistance through the Choice programYesNoProvide a Financial Statement from Your School Showing Your Tuition Cost for Last Calendar Year*For example: If you are applying in 2019, provide us a financial statement that shows your tuition cost for 2018.Accepted file types: pdf, doc, docx.Statement of Purpose*Write a brief statement (minimum of 250 words) that describes how your current academic program will influence your future professional practice and leadership development at Kaiser Permanente.AttestationI have completed this application and provided the supporting documents to the best of my ability.*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. I agree After you click the Submit button, check for a confirmation notice at the bottom of the form. You will also receive a confirmation email. If you do not see the confirmation notice, check through the application form for any missing/incorrect information.