2017 Remembering When Scholarship Conference Application Application Period: June 12 - August 11

Remembering When Scholarship Conference: Nashville, TN November 1-3, 2017

This interest survey fulfills PART A of the application process. Your application is not complete until PARTS A & B are received.

The people listed here should be willing and able to attend the Remembering When Scholarship Conference. Teams cannot be changed after selections are made.

You can construct your responses in a word document and paste them into the survey if you wish.

IMPORTANT: The survey settings allow you to return and modify your responses if you re-enter on the save device. This enables you to view the questions prior to 6.12 and plan your responses. Once you answer the last question as "FINISHED", do not make further changes. Applications will be assessed as they are received after June 12th. Changes made after you mark your survey finished will not be read.

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* 1. Before you begin, please read all of the information about the application process including the FAQs. Click here to read the details.

We have read the information and we are ready to proceed!

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* 2. Community and state/ province your Remembering When team serves:

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* 3. Who is your Team Leader?

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* 4. Which best describes the community you will serve with your Remembering When program?

Urban

Rural

Suburban

Combination (Please explain)

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* 5. Team member #1: Fire Department Representative

Name *

Title *

Fire Department *

Address

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 6. Team member #2: Community Partner

Name *

Title *

Agency *

Address

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 7. Team Member #3: Optional. This person may be a fire department member or a community partner

Name

Title

Dept / Agency

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 8. Home visits are an important part of the Remembering When program. Which team member(s) currently complete home visits as part of her or his job?

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* 9. Describe the existing home visits the team member(s) currently complete:

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* 10. Tell us why your team should be awarded this scholarship. Discuss your community’s need and your team’s ability to make a strong, continued impact on older adult safety by using the Remembering When program.

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* 11. Explain how the local Remembering When team could grow. Tell us about additional community partners who could join your team. Describe the opportunities to train additional fire department and community members.

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* 12. If any team members have attended a Remembering When Scholarship Conference in the past, tell us who, when, and where. Tell us why you should be considered again.