MHA 2007 Annual Meeting
"Bringing Wellness Home"
June 6 - 9, 2007 l Washington, DC
Center for Mental Health Services Application for Financial Support Application deadline: March 30, 2007
The Center for Mental Health Services (CMHS), within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with AFYA, Inc. (AFYA), is providing financial support to consumers of mental health services who would like to participate in the annual conference sponsored by the Mental Health America, formerly the National Mental Health Association. The purpose of the scholarships is to foster transformation of mental health care to focus on recovery. Please note:
To be eligible for this scholarship, a completed application and letter of recommendation must be received by March 30, 2007.
Conference information is available at: www.mentalhealthamerica.net
Please PRINT the following information as you would like it to appear on the participants list. PLEASE DO NOT USE ACRONYMS.
Contact Information:
Name___________________________________________________________
Title___________________________________________________________
Organization/Agency____________________________________________
Mailing
Address________________________________________________________
City__________________________________
State _________________________ Zip ______________________
Telephone (______)_______________Fax (______)_________________
E-mail________________________________________________
Emergency Contact Information:
In case of emergency, please contact:
Name___________________________________________________________
Relationship___________________________________________________
Organization/Agency____________________________________________
Address________________________________________________________
City_____________________________________________________
State _________________________ Zip ______________________
Telephone (______)______________________________
Emergency Telephone (______)________________________________________
Demographic Information (optional):
Gender ____Male ____Female
Age ____18 - 25 ____26 - 55 ____56 +
Ethnicity ____Asian/Pacific Islander ____American Indian
____Black (not of Hispanic origin) ____Hispanic
____White (not of Hispanic origin) ____Other
Sexual Orientation ____Heterosexual ____Gay ____Lesbian ____Bisexual
Physical Disability ____Yes ____No
U.S. Citizen ____Yes ____No
Financial Support:
What type of scholarship support are you seeking? (please check all that
apply) ____Registration Fee ____Hotel ____Per diem ____Ground transportation
Travel costs (please choose one from below) ____Airfare ____Train ____Car Mileage (mileage is based on Federal Regulations - and must not exceed lowest airfare)
Have you received a scholarship from CMHS to attend this conference in the past?
____Yes ____No If yes, what year(s)? __________________
Have you received a scholarship from another sponsor to attend this conference in the past?
____Yes ____No If yes, State sponsor's name. Whatyear(s)? __________________
Logistics Information:
Do you have any lodging limitations that would prohibit double occupancy?
____Yes ____No If yes, state limitation.
Additional Information:
On a separate piece of paper, please provide the review committee with the following information:
1. What are the reasons you wish to attend the conference?
2. Are you making a presentation at this conference? If yes, please
describe.
3. How will you disseminate information obtained at this conference to local
or statewide consumer groups?
4. What are the specific issues relating to mental health in which you are
most interested?
5. Are you currently involved with any related programs and activities?
If
yes, please describe.
Please provide at least one letter of recommendation with your completed application.
Scholarship Conditions:
Please note that to be eligible for this scholarship, you must be a U.S.
citizen and a mental health consumer. If you are selected as a scholarship recipient, a representative from AFYA will contact you to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:
1. Submit to AFYA a 2 to 5 page report in a format provided within 2 weeks
of the conclusion of the conference. Your report will be summarized and
shared with CMHS, other scholarship recipients, the sponsoring
conference organization, and others.
2. Submit to AFYA an evaluation in a format provided within 2 weeks of
the conclusion of the conference.
3. Submit a travel reimbursement form to AFYA within 2 weeks of the
conclusion of the conference.
4. Agree to have your name and contact information shared with other
scholarship recipients. If you would like to keep your contact information
confidential, please contact AFYA.
5. Inform AFYA if you are unable to attend the conference or will be delayed
in meeting any of the above conditions.
Signature________________________________________________________
Date _________________________
Please submit your completed application and letter(s) of recommendation
to:
Lethia A. Kelly, CMP
Senior Conference Manager
AFYA, Inc.
8101 Sandy Spring Road, Suite 301 Laurel, MD 20707
Phone: (301) 957-3049 (Direct)
(301) 957-3040, Ext. 249
Fax: (301) 457-9902
E-mail: lkelly@afyainc.com
Please note that your complete application must be received by AFYA by March 30, 2007