Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. 2019 New England School of Addiction StudiesJune 3 - 6, 2019, Worcester State University, Worcester, MAVermont 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 Summer 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 - Friday, April 15, 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 Summer School registration. If you have not registered for the Summer School, visit 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 Summer 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 Summer School help you on your career path? OK Question Title * 19. How will you use the Summer School learning experience to strengthen Vermont's system of care? OK Question Title * 20. Summer School courses I plan to take (List courses # and titles): 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 on campus in the dormitory. Commute. 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 Question Title * 24. Please note years that you have attended Summer 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 6/3/19. 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
