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| Georgia Association of Nursing Student Chapter of the Year |
| A. MEMBERSHIP Total number of Nursing Students Enrolled: __________ Total Number of NSNA Members: _________________ |
| B. COMMUNITY HOURS DATE PROJECT TOTAL HOURS #OF PARTICIPANTS __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ |
| C. STATE INVOLVEMENT 1. BTN Projects - Recruitment and Retention DATE PROJECT TOTAL HOURS #OF PARTICIPANTS __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ |
| 2. Number of person from your chapter serving as a GANS Officer or a committee member: __________ 3. Number of person from your chapter who ran, or is preslated, for a GANS office within the past year: ________ 4. Number of members from your chapter who attended the 2003 GANS COSP: __________ 5. Number of members from your chapter who attended the 2002 GANS Convention in Augusta: __________ 6. Number of member from your chapter pre-registered to attend the 2003 GANS convention: __________ 7. Please list any State honors or awards received by your chapter or members within the past year: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ |
| D. NATIONAL INVOLVEMENT |
| 1. Number of persons from your chapter currently serving as an NSNA Officer or committee member: ________ 2. Number of persons from your chapter who ran for an NSNA office within the past year: __________ 3. Number of members from your chapter who attended the 2002 NSNA MidYear Convention _________ 4. Number of members from your chapter who attended the 2003 NSNA National Convention: ____________ 5. Please list any National honors or awards received by your chapter or members within the past year: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ |
| Please list any information relevant to this award, which is not covered by the previous data: |
| We hereby certify that all information and statements made in this application are complete and accurate. |
| Chapter President's Signature: _______________________________________________________ Chapter Advisor's Signature: ________________________________________________________ Date: __________________________________________ |
| All applications must be received by September 10, 2004 |
| Please send the complete application & attachments to: GANS Awards Committee c/o Traci Steinhauser 1727 Country Park Way Lawrenceville GA 30043 (404)432-7273 [email protected] |