2 Up to $250 total (receipts required if travel by air). Up to $95 per day of conference attendance

Transcription

1 2016 ICADD Millennium Fund Schlarship Applicatin In the spring f 2015 the ICADD Fundatin was awarded an Idah Millennium Fund grant ffering a limited number f cnference schlarships t supprt attendance by rural prviders f SUD treatment, preventin and calitin building grups. The ICADD Fundatin is grateful t the Idah State legislature fr its supprt f ICADD s effrts t enhance the SUD educatin f thse in rural Idah cmmunities. Dates f cnference: Pre-cnference: May 16, 2016 General cnference: May 17-19, 2016 Guidelines: 1. Only ne schlarship applicatin per persn. 2. Only residents r emplyees f agencies within the State f Idah are eligible fr schlarships. 3. Schlarships are nn-transferable. 4. If eligible, each applicant will be respnsible fr bking/paying fr travel and ldging arrangements. 5. ICADD Fundatin will nt be respnsible fr csts assciated with travel cancellatins r changes. 6. ICADD will reimburse direct airline csts r IRS mileage rate in accrdance with the reginal guidelines belw. 7. Reimbursement will ONLY be prvided t thse wh prvide prf f attendance at ICADD. Prf f attendance will be a cpy f schlarship recipient 2016 CEU frm, stamped at the cnference. 8. Each schlarship will prvide a full cnference registratin, plus reimbursements accrding t the fllwing reginal rates: Regin Travel Ldging 1 Up t $250 ttal (receipts required if travel by air). Up t $95 per day f cnference attendance 2 Up t $250 ttal (receipts required if travel by air). Up t $95 per day f cnference attendance 3 Nne Nne 3 Beynd 30 miles f Bise State Student Unin Building: up t $100 ttal mileage reimbursement. 4 Nne Nne 4 Beynd 30 miles f Bise State Student Unin Building: up t $100 ttal mileage reimbursement. Up t $95 per day f cnference attendance Up t $95 per day f cnference attendance 5 Up t $175 ttal mileage reimbursement. Up t $95 per day f cnference attendance 6 Up t $225 ttal mileage reimbursement. Up t $95 per day f cnference attendance 7 Up t $250 ttal mileage reimbursement. Up t $95 per day f cnference attendance Page: 1 f 5

2 Timelines: September 1-30, 2015: Reginal Behaviral Health Bards (BHB) OR the ICADD Fundatin will distribute and accept this schlarship applicatin. All applicatins must be submitted by 5:00 pm MST n September 30 th. Please refer t the fllwing infrmatin regarding where t submit yur applicatin. Regin Cntact Applicatin Submittal Instructins 1 Angela Palmer, Phne: angela.palmer@sequelyuthservices.cm Mail applicatin t: SAFS Attn: Angela Palmer 1200 Irnwd Drive, Suite 101 CDA, ID ICADD Fundatin Fax applicatin t: ICADD Fundatin Fax applicatin t: ICADD Fundatin Fax applicatin t: Debbie Thmas Fax applicatin t: , Attentin: Debbie Thmas (Please call t advise f incming faxed applicatin) OR t: debbie@thewalkercenter.rg 6 Janae Andersn, Phne: Fax applicatin t: , Attentin: Janae andersej@dhw.idah.gv 7 Mnica Martin, Phne: MartinM@dhw.idah.gv Andersn Fax applicatin t: , Attentin: Mnica Martin September 1-30, 2015: The ICADD website will prvide a cpy f this schlarship applicatin. Octber 1-15, 2015: Each BHB will evaluate and rank rder applicatins. All applicatins will be submitted t the ICADD Fundatin fr final evaluatin by Octber 15 th, By February 1, 2016: Each applicant will be ntified f the results f their schlarship applicatin. Page: 2 f 5

3 Applicant Infrmatin Instructins t applicant: 1. Fill ut pages 3 and Turn this applicatin (pages 1 5) int yur Reginal Behaviral Health Bard OR The ICADD Fundatin at fr prcessing n later than September 30, See page 2 fr instructins n where t submit this applicatin based upn yur regin. First name: Last name: address: (Required: all ntificatins will be sent via . Please ensure this infrmatin is crrect) Hme address: Wrk phne number: (Hme/Cell) phne number: Agency name: Agency address: Department f Health and Welfare Regin yu are representing: Are yu a current student: Yes N If yes, please prvide a descriptin f the degree yu are wrking tward and year f prgress in prgram: Highest pst-secndary educatin level: What percentage f yur time (in years) is cmmitted t the fllwing?: 1. Direct service prvider t treatment end users? 2. In-direct service prvider (i.e.: management) t treatment end users? 3. Direct service prvider t preventin end users? 4. In-direct service prvider (i.e.: management) t preventin end users? 5. Vlunteer fr a cmmunity calitin? 6. Paid staff fr a cmmunity calitin? Number f times yu have attended ICADD in the past? Page: 3 f 5

4 If yu are a licensed r certified prfessinal, please prvide a list f yur credentials. Are yu lcated in a rural lcatin (check: Yes N Are yu willing t attend 3 r 4 days f the cnference (Mnday being a pre-cnference skill building day)? 3 days 4 days Please describe hw attendance at ICADD will affect evidence based practice implementatin (250 wrds r less). If applicable, please have yur direct supervisr prvide a referral nte indicating supprt fr this schlarship (250 wrds r less). Direct supervisr name: If eligible (see criteria n page 1), will yu require ldging if selected as a schlarship recipient? Yes N (Please nte, if yu select NO yu will NOT be reimbursed fr ldging). If eligible (see criteria n page 1), please prvide an estimate f yur rund trip mileage yu will be requesting reimbursement fr OR please indicate if flying will be yur preferred methd f travel t/frm ICADD (Flying: Yes N). Page: 4 f 5

5 BHB USE ONLY This applicatin must be submitted (faxed r scanned) by the BHB t the ICADD Fundatin n later than Octber 15 th, 2015 Reginal Behaviral Health Bard number: Name f persn prcessing this frm fr BHB: The ICADD Fundatin has created the fllwing pint system fr ranking this applicatin by BHB s. Please award 1 pint fr each f the fllwing ICADD pririties met by the applicant: The applicant is a direct service prvider r calitin vlunteer. The applicant has 5 r fewer years prviding direct services r wrking with a calitin. The applicant is frm a rural cmmunity. The applicant has never attended ICADD. The applicant is a student. TOTAL PRIORITY POINTS If faxing this prcessed applicatin, please send t: If scanning/ ing this applicatin, please send t: inf@attendicadd.cm ICADD MF COMMITTEE USE ONLY Applicatin status: Apprved Denied Cmmittee member reviewing this applicatin: Date reviewed: Page: 5 f 5