Application for financial assistance with
Christian Science Nurses Training

Before you begin

Are you interested in becoming a Christian Science nurse with an independent home care ministry?
OR
Are you an active Christian Science nurse pursuing independent home care ministries for Christian Scientists?
YesNo

If you answered "Yes" to this question, you may qualify for a grant from The Dominion Foundation for Christian Science Nursing, Inc. Please complete the application fully to enable us to process your request.

Your information

Name (required)

Email (required)

Phone number (required)

Street address (required)

City (required)

State (required)

Zip code (required)

Monthly income

The more information you include, the more effectively The Dominion Foundation can consider your request for funding.

Wage/Salary
$ 

Social security income
$ 

Annuity
$ 

Dividends/Interest
$ 

Other income
$ 

Total Monthly Income (required)
$ 

Assets

All asset fields are required.

Checking account (required)
$ 

Savings accounts (required)
$ 

Real estate—Home (required)
$ 

Real estate—Other (required)
$ 

Stocks/Bonds (required)
$ 

Insurance (required)
$ 

Other assets (required)
$ 

Total Assets (required)
$ 

Monthly expenses

The more information you include, the more effectively The Dominion Foundation can consider your request for funding.

Mortgage/Rent
$ 

Utilities
$ 

Insurance
$ 

Other expenses
$ 

Total Monthly Expenses (required)
$ 

Liabilities

The more information you include, the more effectively The Dominion Foundation can consider your request for funding.

Mortgage
$ 

Debt
$ 

Other liabilities (please explain)

Total Liabilities (required)
$ 

Training information

Christian Science Nurse Education Program that has accepted you (required)

Christian Science Nurse Education Course that you will be taking (required)

Your present status: (required)
New student1st year2nd year3rd year

Training expenses

Tuition and fees (required)
$

Other resources of financial assistance for tuition (required)

Travel (required)
$

Other resources of financial assistance for travel (required)

Other expenses (required)
$

Other resources of financial assistance for other expenses (required)

Estimated financial assistance needed (required)
$ 

Additional information

How many Christian Science home nursing cases have you had to date? (required)

How will this training help you be a better home care Christian Science nurse? (required)

Do you currently have transportation to make home Christian Science nursing calls? (required)
YesNo

If you are now affiliated with a Christian Science facility or residence, how will home Christian Science nursing cases affect your duties there? (required)

Please provide the name of at least one individual affiliated with Christian Science nursing whom we may contact regarding your work as a Christian Science nurse. (required)

Name

Title or affiliation with Christian Science nursing

Phone number

Form submission

I affirm that all information provided is accurate, and I understand that submission of this form constitutes my digital signature. (required)
I agree to this statement.