MA AFCC Scholarship Application for the National Conference

1. MA AFCC Scholarship Application for the National Conference

In conjunction with the Association of Family and Conciliation Courts, the Massachusetts Chapter of the AFCC is offering one (1) scholarship for the AFCC’s 49th Annual Conference which is taking place in Chicago, Illinois from June 6 – 9, 2012. The scholarship will cover up to $565.00 in registration fees for the Annual Conference. If you are interested in applying for the scholarship, please complete this survey on or before March 16, 2012 at 5:00 p.m. Please note the scholarship is available only to members of the MA Chapter of the AFCC. Your application will be reviewed only by the Review Committee and will be kept confidential.

Question Title

* 1. Contact Information. Please provide your contact information.

Name: *

Discipline: *

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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* 2. Are you a member of AFCC and MA- AFCC?

Yes

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* 3. Have you ever attended an AFCC conference? If your answer is yes, please indicate when.

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* 4. Will you receive any funding support from your employer or other source outside of MA AFCC?

Yes

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* 5. Are you compensated for attending the conference?

Yes

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* 6. What is your current earned income?

Less than $30,000

$30,000 - $44,000

$45,000 - $59,000

$60,000 - $74,000

Greater than $74,001

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* 7. How many people are dependent on you financially (do not include yourself)

5 or more

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* 8. What is your combined household income?

Less than $30,000

$30,000 - $44,000

$45,000 - $59,000

$60,000 - $74,000

Greater than $74,001

MA AFCC Scholarship Application for the National Conference

1. MA AFCC Scholarship Application for the National Conference

Question Title

* 1. Contact Information. Please provide your contact information.

Question Title

* 2. Are you a member of AFCC and MA- AFCC?

Question Title

* 3. Have you ever attended an AFCC conference? If your answer is yes, please indicate when.

Question Title

* 4. Will you receive any funding support from your employer or other source outside of MA AFCC?

Question Title

* 5. Are you compensated for attending the conference?

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* 6. What is your current earned income?

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* 7. How many people are dependent on you financially (do not include yourself)

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* 8. What is your combined household income?

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* 9. Describe how your attendance at this conference will impact your work. Please limit your response to 150 words or less.

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* 10. Describe your involvement with the AFCC or AFCC MA Chapter in the last five (5) years. Please limit your response to 150 words or less.