Substance Abuse & Mental Health Services Administration

CMHS Consumer Affairs E-News
December 14, Vol. 07-200

2008 ACMHA Santa Fe Summit

"Impacting Healthcare Reform '08 Leadership in Moving the Mental Health and Substance Use Agenda"
March 13 - 15, 2008
Eldorado Hotel & Spa
390 W. San Francisco
Santa Fe, NM 87501

ACMHA APPLICATION FOR FINANCIAL SUPPORT

Application postmark deadline: January 3, 2008

Each year the American College of Mental Health Administration (ACMHA), in conjunction with the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration, and other funders is pleased to be able to provide financial support to consumers of mental health services to participate in the ACMHA Santa Fe Summit. The purpose of the scholarships is to foster the transformation of mental health care and to bring to the Summit individuals who can actively participate in, contribute to, and learn from and with other members of the behavioral health community. Scholarship recipients are selected from the pool of applications received, with consideration given to geographic representation, age/gender/race/ethnicity diversity, and individuals who have not previously attended an ACMHA Summit. Please note: To be eligible for this scholarship, you must be a US citizen, a mental health consumer, and submit a completed application postmarked by January 3, 2008.

More information about the Summit is available at http://www.acmha.org/summit/summit_2008.cfm.

Contact Information:

Please PRINT the following information as you would like it to appear on the participants list.

Name _____________________________________

Title ______________________________________

Organization/Agency __________________________

Mailing Address _____________________________

City ______________________________________

State _________________________

Zip ______________________

Telephone (______)_______________

Fax (______)_________________

E-mail _____________________________________

In case of emergency, contact: ___________________________________________

Telephone (______)___________________________

Demographic Information (optional):

Gender

Age

Race/Ethnicity

Physical Disability

___ Male   ___ Female

___ 18 - 25
___ 26 - 40
___ 41 - 55
___ 56 +

____ Asian/Pacific Islander

____ American Indian

____ Black (not of Hispanic origin)

____ Hispanic

____ White (not of Hispanic origin)

____ Other

Physical Disability

____ Yes _____ No

Please make a copy of this completed form for your records.

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 ACMHA to attend the Summit in the past?

____ Yes _____ No

If Yes, what year(s)? ___________________

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

____ Yes ___ No

If Yes, provide sponsor's name: ____________________

What year(s)? ___________________

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

_____ Yes _____ No

If yes, indicate limitation: ___________________________________________________________

Additional Required 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 Summit?
2. How will your participation in the Summit assist you? What purpose does it bring to your work or your advocacy? Attach a letter of recommendation.

Scholarship Conditions:

If you are selected as a CMHS scholarship recipient, a representative from AYFA, Inc. will contact you by January 31, 2008 to discuss travel and lodging arrangements, which will be made for you. As a scholarship recipient, you will be asked to do the following:

1. Complete a meeting report following the Summit that will be shared with CMHS and ACMHA.
2. 2. Complete and return an evaluation sent to you by ACMHA one month following the conclusion of the Summit.
3. Inform ACMHA if you are unable to attend the Summit or will be delayed.

PLEASE NOTE:

Lodging scholarships cover the amount of room and tax for 3 nights only; checking-in on March 12 and checking-out on March 15.

Signature _____________________________________________________

Date _________________________

Please mail your completed application to:

Kris Ericson, PhD, Executive Director
ACMHA
7804 Loma del Norte Rd NE
Albuquerque, NM 87109-5419

Completed documents must be sent via the USPS to the address above and postmarked no later than January 3, 2008. Late applications will not be considered.

ACMHA gratefully acknowledges the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, for its support.

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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.