Substance Abuse & Mental Health Services Administration

Age

Ethnicity

Sexual Orientation

Special Needs
Physical Disability:

Medical Condition:

U.S. Citizen

Financial Support:

What type of scholarship support are you seeking? (Please check one.)

What type of funding are you seeking? (Please check all that apply.)

Travel Costs (Please choose one from below.)

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

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

Logistics Information:
Do you have any special needs that would prohibit double occupancy?

If yes, please list any special needs: _________________________________________________________________________

Additional Information:

On a separate piece of paper, please provide the review committee with the following information:

1. Why do you wish to attend the conference?

2. Are you making a presentation at this conference? If yes, please
describe.

3. How you will 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 by June 16, 2006, to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit to AFYA, within 2 weeks of the conclusion of the conference, a 2-5
page report in a format [WHO?] will provide. Your report will be
summarized and shared with CMHS, other scholarship recipients, the
sponsoring conference organization, and others.

2. Submit to AFYA, within 2 weeks of the conclusion of the conference, an
evaluation in a format AFYA, Inc. will provide.

3. Submit to AFYA, within 2 weeks of the conclusion of the conference, a
travel reimbursement form .

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 IMMEDIATELY if you are unable to attend the conference or
if you will be delayed in meeting any of the above conditions.

Signature_______________________________________________________ Date _________________________ Please submit your completed application and letter(s) of recommendation BY US MAIL ONLY to:

Lethia A. Kelly, Senior Conference Manager, AFYA, Inc.
6930 Carroll Avenue, Suite 1000, Takoma Park, Maryland, 20912, Phone: (301) 270-0841, Ext. 249
E-mail: lkelly@afyainc.com
Please note that your complete application must be postmarked on or before May 19, 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.