de Souza Clinical Fellowship Application

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Citizenship

Citizenship Canadian Citizen Permanent Resident

Only Canadian Citizen or Permanent Resident are eligible to apply
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employer's Name
Primary Email Address
Work Email
Specialty Certification

Specialty Certification CNA oncology specialty CNA hospice palliative Care specialty ONCC pediatric hematology specialty

Indicate all specialty certification obtained
Please indicate the focus of your clinical fellowship, check the most appropriate box

Please indicate the focus of your clinical fellowship, check the most appropriate box Clinical Educational Leadership Research Other (please give details below if "Other" is selected)
Add focus, if "Other" is selected above
Location of Clinical Fellowship
Nursing Education Background (Indicate all degrees obtained):

Nursing Education Background (Indicate all degrees obtained): RN (diploma) RN (degree) RN Master’s or higher

Indicate all degrees obtained
____________________________________________________________________
Letter of Intent
- Applicants who work towards a de Souza nurse designation can request financial support. A one page letter of intent is required on the proposed clinical fellowship, and how this fellowship will contribute to the applicant’s personal growth, and meet the local needs when returning to the home institution.
- Applicants who work towards a de Souza APN designation can also request financial support. A two page letter of intent is required to outline how the proposed clinical fellowship will support clinical, educational, and leadership development of the applicant and how the applicant will translate learning into change of practice in the home institution. Applicants should also include information regarding their proposed evaluation or research project to be implemented in their organization and how this will contribute to the advancement of Oncology and/or Palliative Care
Attach a Copy of your Registration/Membership to your province's professional college (i.e. College of Nurses of Ontario, College and Association of Registered Nurses of Alberta, etc)

Attach Files
Attach a Copy of CNA Certification in Oncology, Hospice Palliative Care or CPHON

Attach Files
Attach Your Letter of Intent

Attach Files
Attach your Learning Plan for the Clinical Fellowship

Attach Files

If you have any additional document(s) to support your application please attach them here.
Attach a Letter of Support from Your Employer (Manager or Director) for This Fellowship

Attach Files
Resume / Curriculum Vitae (CV)

Attach Files
By typing my information below I confirm that the information provided in the application is complete and accurate. The provision of false information may result in the termination of funding and dis-entitlement from eligibility for future funding.
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Confirm Primary Email Address

Confirm Primary Email Address as entered above
Date of Submission

de Souza Clinical Fellowship Application

de Souza Clinical Fellowship Application

By typing my information below I confirm that the information provided in the application is complete and accurate. The provision of false information may result in the termination of funding and dis-entitlement from eligibility for future funding.