MA Metro West Summer School Scholarship Form - New England Institute of Addiction Studies

MA Metro West Summer School Scholarship Form

2016 New England School of Addiction And Prevention Studies

Scholarships

Massachusetts Bureau of Substance Abuse Services Metro West Region Scholarships

The Massachusetts Department of Public Health, Bureau of Substance Abuse Services, provides limited partial scholarship awards.

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

Deadline for scholarship applications - Extended to Friday, April 22, 2016.

Be sure to fill out the entire application.

For scholarship related questions, please contact:

Kim Burnett

Metro West Region

MA Department of Public Health, Bureau of Substance Abuse Services
Donovan Health Building, 5 Randolph Street, Canton, MA 02021

Switchboard: (781) 828-7700
Direct Line: (781) 828-7793
FAX: (781) 828-7703
Boston: (617) 624-5139

Kim.Burnett@state.ma.us

*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 school, to register, you must click here to complete the Summer School online registration form.

Scholarship Application Form:

Contact Information

First Name *		Last Name *
Email Address
Employer
Street Address *		City *
State		Zip Code *
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 enrolled in substance abuse courses (please specify university below) Other (Please specify below)
Other Role DescribedPlease describe your role if you selected "other", and include university or college if you selected "student".
Position Title *
Length of Time Working in Substance Abuse Field *
Length of time in current job *
Level of Education *
Licensures or CertificationsPlease note any licensures or certifications here.


Please list three major responsibilities of your current job.

3 Major Job Responsibilities *Please list the major responsibilities on your current job.
Primary Focus of Your Program *Please note the primary focus of program.
Summer School courses I plan to take *Please note the courses that you plan to take at the Best Practices school.


Briefly comment in your interest in attending 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. Enter years, comma separated. *
Have you received a Summer School scholarship in the last 5 years? Enter years, comma separated. *
If yes, please note the entity that awarded the scholarship


Payment Planning

If selected, you will be responsible for ensuring payment of any remaining portion of your balance. *	I understand that, if selected, I am responsible for any balance due by 6/6/16.


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.	I will pay for my registration. My employer will pay for my registration. My employer and I will pay for my registration. I will withdraw my registration.
Will you be commuting or staying dormitory lodging? *	Commuting Staying in dormitory lodging
If commuting, please note how many days you will attend:	4 3 2 1
Supervisor Information

Supervisor's Name *
Supervisor's Email
Supervisor's Telephone
Additional CommentsPlease note any additional comments for consideration.

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