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I would like to commit to:

The DAISY Award for Extraordinary Nursing StudentsThe DAISY Award for Extraordinary Nurse Educators
Both

Please complete all boxes below to tell us how you intend to implement The DAISY Award for Extraordinary Nursing Students or The DAISY Award for Extraordinary Nurse Educators.

About Your Academic Institution

Name of your Academic Institution and Department or School/College of Nursing as you would like it listed on our roster of Participating Organizations (e.g. Florida Atlantic University; Christine E. Lynn College of Nursing)

Do you have multiple campuses ?

YesNo

Please list the campuses that will participate in your DAISY Program.

Nursing Degree Programs Offered:

ADN/LPNRN/BSNPost Baccalaureate

Is your academic institution online only? :

Yes- Online OnlyNo

What is your approximate Academic Calendar?

Quarters

Semesters

Other

Your school/college's web address (e.g. www.school.edu)

Approximate number of Nursing Students

Approximate number of Faculty Members

Your DAISY Student Award Plan:

How many Student Awards per Calendar Year do you plan to present (you may change this, later)?

At what event do you think you will conduct your presentation ceremony (you may change this, later)?

Pinning ceremonyConvocationCommencementGraduationIn the classroom during classesFaculty RetreatOther

Where did you learn about The DAISY Award for Extraordinary Nursing Students?

Approximately when do you intend to have your first Award presentation ceremony? (We know you may not have an exact date, now, but please choose an approximate date for planning purposes.)

Name of the Committee or Team that will run your DAISY Award for Extraordinary Nursing Students Program:

Who will be your DAISY Student Award Coordinator?

First Name

Last Name

Credentials

Title

Phone

Email

To whom should we ship your DAISY Student Award gifts and materials?

Is the person we are shipping to the same as your Student Award Coordinator above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

Street Address

Shipping mailstop/office building/room #, etc.

City

Country

State:

Provinces

State/Province

Postal Code

To whom should the invoice for your program be sent ($120 per Award)?

We will touch base with you before we send the invoice.

Is the person we are emailing the invoice to the same as your Student Award Coordinator above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

About Your Dean:

Is your Dean the same person as the DAISY Coordinator listed above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

Your DAISY Nurse Educators Award Plan:

How many Nurse Educators Awards per Calendar Year do you plan to present (you may change this, later)?

At what event do you think you will conduct your presentation ceremony (you may change this, later)?

Pinning ceremonyConvocationCommencementGraduationIn the classroom during classesFaculty RetreatOther

Where did you learn about The DAISY Award for Extraordinary Nurse Educators?

Approximately when do you intend to have your first Award presentation ceremony? (We know you may not have an exact date, now, but please choose an approximate date for planning purposes.)

Name of the Committee or Team that will run your DAISY Award for Extraordinary Nurse Educators Program:

Who will be your DAISY Nurse Educator Award Coordinator?

First Name

Last Name

Credentials

Title

Email

Phone

To whom should we ship your DAISY Nurse Educators Award gifts and materials?

Is the person we are shipping to the same as your Nurse Educator Award Coordinator above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

Street Address

Shipping mailstop/office building/room #, etc.

City

Country

State

Provinces

State/Province

Postal Code

To whom should the invoice for your program be sent ($150 per Award)?

We will touch base with you before we send the invoice.

Is the person we are emailing the invoice to the same as your Nurse Educator Award Coordinator above?

First Name

First Name

Last Name

Last Name

Title

Title

Credentials

Credentials

Email

Email

Phone

Phone

About Your Dean

Is your Dean the same person as your Nurse Educator Award Coordinator, above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

Who will be your DAISY Student Award Coordinator?

First Name

Last Name

Credentials

Title

Phone

Email

Nurse Educator Award Coordinator

Is your Nurse Educator Award Coordinator the same person as your Student Award Coordinator?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Phone

Phone

Email

Email

To whom should we ship your DAISY Student Award gifts and materials?

First Name

Last Name

Credentials

Title

Email

Phone

Street Address

Shipping mailstop/office building/room #, etc.

City

Country

State:

Provinces

State/Province

Postal Code

To whom should we ship your DAISY Nurse Educator Award gifts and materials?

Is your shipping information for your Nurse Educator the same as your Student Award, above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

Street Address

Street Address

Shipping mailstop/office building/room #, etc.

Shipping mailstop/office building/room #, etc.

City

City

Country

State:

Provinces

State/Province

Postal Code

Postal Code

To whom should the invoice for your Student program be sent ($120 per Award)?

We will touch base with you before we send the invoice.

First Name

Last Name

Credentials

Title

Email

Phone

To whom should the invoice for your Nurse Educator program be sent ($150 per Award)?

We will touch base with you before we send the invoice.

Is your invoicing information for your Nurse Educator Award the same as your Student Award, above?

First Name

First Name

Last Name

Last Name

Credentials

Credentials

Title

Title

Email

Email

Phone

Phone

About Your Dean

First Name

Last Name

Credentials

Title

Email

Phone

Marketing/ Public Relations Contact

We recommend having someone from your marketing or public relations department work with your DAISY committee to raise awareness of your program among students and staff. Please tell us if you would like us to contact one of your representatives to assist in this process.

First Name

Last Name

Credentials

Title

Phone

Email

Acknowledgement and Form Completion

In case we need to contact you with a question, may we have the full name of the person who completed this form, please?

May we have the email address of the person who completed this form, please?

Note: is there anything else you want us to know?

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

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