Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
March 28, 2006, Vol. 06-37

*****REMINDER*******

NMHA 2006 Annual Meeting
"Building the Movement"
June 8 - 10, 2006
Washington, DC

Center for Mental Health Services Application for Financial Support Application deadline: March 31, 2006

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 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 31, 2006.

Conference information is available at: www.nmha.org.

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

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. What year(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
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.