Substance Abuse & Mental Health Services Administration

Age

Ethnicity

Sexual Orientation

Physical Disability

Financial Support:

What type of scholarship support are you seeking? (please check all that apply)

Have you received a scholarship from CMHS to attend this conference in the past?

Have you received a scholarship from another sponsor to attend this conference in the past?

Do you have any lodging limitations that would prohibit double occupancy?

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
Senior Conference Manager
AFYA, Inc.
6930 Carroll Avenue, Suite 1000
Takoma Park, Maryland, 20912
Phone: (301) 960-0149 (Direct) or (301) 270-0841, Ext. 249 Fax: (301) 270-5099 Pager: 800-978-4736
E-mail: lkelly@afyainc.com

Please note that your complete application must be received by AFYA by March 31, 2006
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The Center for Mental Health Services is a component of the Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services.