Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. 2020 Virtual New England School of Addiction and Prevention StudiesJune 1 - 4, 2020 by VideoconferenceVermont ADAP Scholarship Application The VT Department of Health, Division of Alcohol and Drug Abuse Programs, provides limited partial scholarship awards, with priority given to: People working in Vermont’s system of care for alcohol and drug prevention, treatment, and recovery Diverse populations and underserved groups People who have not received a scholarship in the past 2 years Deadline for scholarship applications - May 8, 2020 Be sure to fill out the entire application. For scholarship related questions, please contact: Ariel Carter, Manager of Planning & Community Services VT Dept. of Health, Division of Alcohol & Drug Abuse Programs Ariel.Carter@vermont.govandMarcia LaPlanteDirector of Planning & Community ServicesVT Dept. of Health, Division of Alcohol & Drug Abuse Programs Marcia.LaPlante@vermont.gov *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. After you have completed the application, click on the "CLICK HERE TO SUBMIT SCHOLARSHIP APPLICATION" button at the bottom of the page.Please note that a scholarship application is separate from your Summer School registration. If you have not registered for the Summer School, visit the Summer School web page and follow the registration link. OK Contact Information OK Question Title * 1. First Name OK Question Title * 2. Last Name OK Question Title * 3. Email Address OK Question Title * 4. Alternate Email Address OK Question Title * 5. Employer OK Question Title * 6. Street Address OK Question Title * 7. City OK Question Title * 8. State (You MUST work in VT to apply for a VT scholarship): CT ME MA NH RI VT OK Question Title * 9. Zip Code OK Question Title * 10. Is the above address a home address or work address? Work Address Home Address OK Question Title * 11. Work Telephone OK Question Title * 12. Mobile Telephone OK Question Title * 13. Home Telephone (if not same as mobile phone) OK About Your Job, Experience, and Professional Development OK Question Title * 14. Job Sector A professional working in alcohol and other drug prevention services A professional working in alcohol and other drug recovery services A professional working in alcohol and other drug treatment services Mental health/co-occurring disorders treatment services Volunteer in the substance use disorder field Student in mental health/substance use disorder field Recovery Coach State Employee A professional working in Primary Health Care Other with interest in Substance use disorder prevention and treatment Other* * Explain Other Job Sector OK Question Title * 15. Licensures or Certifications: No Licensure/Certification Apprentice Addictions Professional Licensed Alcohol & Drug Counselor Licensed Social Worker Certified Alcohol & Drug Counselor Certified Prevention Specialist Licensed Mental Health Clinician Licensed Marriage & Family Therapist Recovery Coach Psychologist Other* Explain Other Licensure / Certification* OK Question Title * 16. Do you in any way provide services for individuals with opioid use disorder? Yes No OK Question Title * 17. Are you working toward certification or licensure? Not working toward any licensure / certification Apprentice Addictions Professional Licensed Alcohol & Drug Counselor Licensed Social Worker Certified Alcohol & Drug Counselor Certified Prevention Specialist Licensed Mental Health Clinician Licensed Marriage & Family Therapist Recovery Coach Psychologist Other* Explain Other Licensure / Certification working toward* OK Briefly comment in your interest in attending the Summer School. OK Question Title * 18. How will attending help you better serve people with substance use or co-occurring disorders? OK Question Title * 19. How will attending the Summer School help you on your career path? OK Question Title * 20. How will you use your summer school learning experience to better outreach to diverse populations and underserved groups? OK Question Title * 21. Summer School courses I plan to take (List courses # and titles): OK Question Title * 22. I will be attending the program for: 4 days (full program) 3 days 2 days 1 day OK Previous Summer School Attendance and Summer School Scholarships OK Question Title * 23. Have you received a Summer School scholarship in the last two years? Enter years, comma separated. OK Payment Planning OK Question Title * 24. Scholarship Amount Requested: OK If selected, you will be responsible for ensuring payment of any remaining portion of your balance.In many cases, partial scholarships are awarded . OK Question Title * 25. If selected: If awarded a partial scholarship, I understand that I am responsible for any amount due by June 1, 2020. OK Question Title * 26. Balance will be paid by: My employer Me My employer and me OK Question Title * 27. If you do not receive a scholarship: My employer will pay for my registration. I will pay for my registration. My employer and I will pay for my registration. I will withdraw my registration. OK Question Title * 28. Additional Comments: OK CLICK HERE TO SUBMIT SCHOLARSHIP APPLICATION