Vermont Summer School Scholarship Form - AdCare Educational Institute of New England

Vermont Summer School Scholarship Form

2017 New England School of Addiction and Prevention Studies

June 5 - 8, 2017, Worcester State University, Worcester, MA

Vermont Department of Health, Division of Alcohol & Drug Abuse Programs Scholarships

The VT Department of Health, Division of Alcohol & Drug Abuse Programs, provides limited partial scholarship awards, with priority given to those who have not received a scholarship in the past two years.

Any remaining balance and travel are the responsibility of the participant. Scholarships are paid directly to NEIAS. You, and/or your agency, are responsible for paying the remainder of program fees.

Deadline for scholarship applications - Thursday, April 27, 2017

Be sure to fill out the entire application.

For scholarship related questions, please contact:

Patty Baroudi, Prevention Program Manager

VT Dept. of Health, Division of Alcohol & Drug Abuse Programs

Patty.Baroudi@vermont.gov

802-651-1559

*Scholarship funds are limited. Filling out an application is not a guarantee of award.

Scholarship Application Instructions:

Please complete the form below to be considered for a scholarship from your state agency.

Required questions are noted with a red star.

In the last section, click on the orange "Submit" button to submit your scholarship application. Once your application is submitted, you will see a page that says "Thank you for your application". You will also see a small printer near the top of the page, which you can select to print a copy of your submitted application for your files.

Please note that a scholarship application is separate from your Summer School registration.

If you have not registered for the Summer School, visit www.neias.org, and click on the "Summer School" menu and select the "Register" link.

Scholarship Application Form:

Contact Information

First Name *
Last Name *
Email Address *
Alternate Email Address
Employer
Street Address *
City *
State (Must Work in VT) *	CT MA ME NH RI VT
Zip Code *
Is the above address a home address or work address?

Home or work address? *Please note whether this is your home address or a work address.	Home Address Work Address
Work Telephone
Mobile Telephone
Home TelephoneHome Telephone (If different from mobile telephone):
About Your Job, Experience, and Professional Development

Role - I am: *Please select those areas that apply to your professional or volunteer role.	A professional working in alcohol and other drug (AOD) treatment services A professional working in alcohol and other drug (AOD) prevention services A professional working in mental health/co-occurring disorders treatment services A professional working in alcohol and other drug (AOD) recovery support services A state employee whose job requires knowledge of AOD services A volunteer working in the AOD and recovery field A representative of another profession or community with interest in learning more about AOD A student registered in the substance use disorder field (specify where in "Other" below) Other (Please specify below)
Other DetailsPlease describe your role if you selected "other", and include university or college if you selected "student".
Title of Current Position *
Length of Time Working in Substance Use Disorder Field *
Length of time in current job *
Level of Education *
Licensures or CertificationsPlease note any licensures or certifications here.
Primary Focus of Your Program *Please note the primary focus of program.
Summer School courses I plan to take *
Briefly comment in your interest in attending the Summer School.

Interest in attending *Briefly comment in your interest in attending the Best Practices School, and how this continuing education experience will help you in your work.
Previous Summer School Attendance and Summer School Scholarships

Years Attended Summer School *Please note years that you have attended Summer School, separated by commas.
If you have you received a Summer School scholarship in the last 5 years, please note the year(s): *
If yes, please note the entity that awarded the scholarship(s):If you have received a Best Practices scholarship(s) within the past 5 years, please note the entity awarding the scholarship(s).
Payment Planning

If selected, you will be responsible for ensuring payment of any remaining portion of your balance.

If selected *	I understand that, if selected, I am responsible for any balance due by 6/5/17.
Scholarship Amount Requested *
In many cases, partial scholarships are awarded. If you receive a partial scholarship:

Balance will be paid by: *If you receive a partial scholarship, please note how your balance will be paid.	My employer Me My employer and me
If you do not receive a scholarship: *Please indicate your plans in the event that you do not receive a scholarship.	Please withdraw my school registration. I will pay for my registration. My employer will pay for my registration. My employer and I will pay for my registration.
Additional CommentsPlease note any additional comments for consideration.

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