Application

GENERAL INFORMATION

First name 

Last name

Address 

City State 

Zip code (Example: 12345-6789) 

Telephone#: 

E-mail Address 

Date of Birth (mm/dd/yy) (optional): 

Social Security #(optional) 

Sponsoring Organization/Institution: 

Sponsor's Address: 

City State 

Zip code (Example: 12345-6789) 

Sponsor's Telephone#: 

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RECOMMENDATION

Please submit one letter of recommendation from an official representing your sponsoring organization. The recommendation should address the following: intellectual curiosity, leadership potential, motivation, concern for others, professional commitments, and potential to influence health policy.

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DESIRED PERSONAL OUTCOMES
For this online form, state a list of your professional goals in the box below. Then follow up with a postal mailing or fax that gives a Summary Description of your goals in greater detail.

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PERSONAL COMMITMENT AGREEMENT

I agree to make a personal commitment to a leadership initiative within a year of completing the Amy V. Cockcroft Nursing Leadership Development Program.

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If you have a question, email Lydia Zager lrzager@gwm.sc.edu  

CHECKLIST  Required for all applicants

• Complete all items on this application (online)
• Send a Summary Description of your professional goals (To be mailed or faxed. The fax number is 803-777-6800)
• Obtain signature from the person approving the program for applicant and a letter of recommendation from the applicant's supervisor (to be mailed or faxed. The fax number is 803-777-6800)
• Make a copy for your records
• For postal mailing, send two copies of your resume or current curriculum vitae to:

Amy V. Cockcroft Nursing Leadership Development Program
ATTN: Lydia Zager 
Room 212
College of Nursing
University of South Carolina
Columbia, SC 29208