Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. 2019 New England School of Best PracticesAugust 19 - 22, 2019Waterville Valley Conference Center, Waterville Valley, NHVermont 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 People who have not received a scholarship in the past 2 years People who have not attended Best Practices School in the past 5 years Any remaining balance and travel are the responsibility of the participant. Scholarships are paid directly to AdCare Educational Institute. You, and/or your agency, are responsible for paying the remainder of program fees. Deadline for scholarship applications - Wednesday, July 31, 2019 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.gov802-951-5191 *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 star. 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 Best Practices School registration. If you have not registered for the Best Practices School, visit the "Best Practices" link at www.neias.org. 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 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. 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 Best Practices School. OK Question Title * 17. How will attending help you better serve people with substance use or co-occurring disorders? OK Question Title * 18. How will attending the Best Practices School help you on your career path? OK Question Title * 19. How will you use the Best Practices School learning experience to strengthen Vermont's system of care? OK Question Title * 20. Best Practices School courses I plan to take: OK Question Title * 21. I will be attending the program for: 4 days (full program) 3 days 2 days 1 day OK Question Title * 22. While attending the school, I plan to: Stay in shared Town Square Condo lodging within the Waterville Valley Resort Stay in a hotel within the Waterville Valley Resort Not require lodging Other OK Previous Best Practices School Attendance and Best Practices School Scholarships OK Question Title * 23. Have you received a Best Practices School scholarship in the last two years? Enter years, comma separated. OK Question Title * 24. Please note years that you have attended Best Practices School. Enter years, comma separated. OK Question Title * 25. If yes, please note the entity that awarded the scholarship. OK Payment Planning OK Question Title * 26. 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 * 27. If selected: If awarded a partial scholarship, I understand that I am responsible for any amount due by 9/19/19. OK Question Title * 28. Balance will be paid by: My employer Me My employer and me OK Question Title * 29. 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 * 30. Additional Comments: OK CLICK HERE TO SUBMIT SCHOLARSHIP APPLICATION