The Northwestern Ontario Regional Stroke Network Education Fund Application

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First Name *

Last Name *

Email Address *

Phone Number *

Manager is aware of application *

If you are scheduled to work the day(s) of the event, approval for time off is required BEFORE your application is processed. Has your manager approved your time off? *

If ‘No’ please describe:

Manager Name *

Organization *

Department *

Address 1 *

Address 2

City *

Job Title *

Discipline *

If 'Other' please describe

Sector *

(Where you spend the majority of work time)

Event Title *

Event Start and End Dates *

Location of Event *

Description of Conference, Workshop, or Course *

Registration, Conference or Tuition Fees:

Projected Travel Fees:

e.g. airfare, bus, subway, taxi

Projected Accommodation Cost:

Projected Meals Cost:

Total Amount Requested: *

(Allocated funding will not exceed this amount)

Have you applied elsewhere for funds pertaining to this application?

e.g. within your organization or to your Professional Association. If yes, where? Amount requested.

Explain how the learning opportunity will benefit the following targeted audiences. Please include all that are applicable. *

Your stroke practice e.g. professional development, level of stroke knowledge. Stroke survivors and their families. Your organization, including colleagues. Health care providers in the region.

Describe your specific plan to share your learning with each of the following targeted groups: *

Within your organization. Regionally e.g. health care providers working in Northwestern Ontario. Support the work of the Northwestern Ontario Regional Stroke Network (Fewer Strokes, Better Outcomes).

Please identify the target audience of your learning plan by discipline and location *

e.g. all health professionals working with stroke in Northwestern Ontario or nurses working in stroke prevention clinics in Northwestern Ontario.

Please identify the target date for sharing your learning. *

Have you previously received funding from the Northwestern Ontario Regional Stroke Network Education Fund?

If ‘Yes’ please provide details, i.e. conference title, location, date and how you disseminated the learning: