CMHS Consumer Affairs E-News
December 16, 2003, Vol. 03-116

SAMHSA/CMHS Consumer Scholarships Available for NMHA 2004 Conference

The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA), through a contract with Westat/Health Systems Research, Inc. (HSR), is providing financial support to consumers of mental health services who wish to participate in the annual conference sponsored by the National Mental Health Association (NMHA). Please note, the completed application (below) and letter or recommendation must be received by March 5, 2004 in order to be eligible for this scholarship.

The National Mental Health Association (NMHA) 2004 Annual Conference
Hyatt Regency Washington on Capitol Hill, Washington, DC
June 9-12, 2004

Conference information available at: 1-800-969-6642 or www.nmha.org

Application for Financial Support
Application deadline: March 5, 2004

Consumer Scholarship Application

Contact Information:

NAME:
ORGANIZATION:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
E-MAIL:

Demographic Information:

Optional Information. The following optional information is intended to help ensure diversity of scholarship recipients. Provision of this information is voluntary and does not affect chances of acceptance.

Gender:
Male ____
Female ____

Age:
18 - 25 ____
26 - 55 ____
56 + ____

Ethnicity:
Asian/Pacific Islander ____
American Indian ____
Black (not of Hispanic origin) ____
Hispanic ____
White (not of Hispanic origin) ____
Other ____

Sexual Orientation:
Lesbian ____
Bisexual ____
Heterosexual ____
Gay ____

Physical Disability:
Yes ____
No ____

Are you a U.S. citizen?
Yes ____
No ____

Financial Support:

What type of scholarship support are you seeking (please check all that apply)?
Registration fee ____
Hotel expense ____
Per diem ____
Ground transportation ____

Travel costs (please choose one from below)
airfare ____
train ____
mileage for car ____

Have you attended this conference in the past?
Yes ____
No ____

If yes, what year(s)? ____

Have you ever received a scholarship to attend the NMHA conference in the past?
Yes ____
No ____
If yes, what year(s)? ____

Additional Information:

On a separate piece of paper, please provide the review committee with the following information:

1. What are the reasons you wish to attend the conference?
   
   
2. How you will disseminate information obtained at this conference to local or statewide consumer groups?
   
   
3. What are the specific issues relating to mental health in which you are most interested?
   
   
4. Are you currently involved with any related programs and activities? If yes, please describe.

Please provide at least one letter of recommendation with your completed application.

Scholarship Conditions:

Please note that in order to be eligible for this scholarship you must be a U.S. citizen and a mental health consumer. If you are selected as a scholarship recipient, a representative of HSR will contact you by May 7, 2004 to discuss travel arrangements. As a scholarship recipient, you will be asked to do the following:

1. Submit a 2 to 5 page report to HSR within 2 weeks of the conclusion of the conference in a format provided by HSR.
   
   
2. Submit an evaluation to HSR within 2 weeks of the conclusion of the conference.
   
   
3. Submit a travel reimbursement form to HSR within 2 weeks of the conclusion of the conference.
   
   
4. Inform the HSR if you are unable to attend the conference or will be delayed in meeting the other two conditions.

Your signature below indicates that you have read and agree with the terms above.

Signature _________________________

Date _________________________

Completed applications and letter(s) of recommendation must be received by March 5, 2004 by:

Stephanie Hauser
Health Systems Research, Inc.
1200 18th Street, NW, Suite 700
Washington, DC 20036
Phone: (202) 828-5100
Fax: (202) 728-9469
E-mail: shauser@hsrnet.com
Pager: (800) 619-4175

(Please leave your phone number including area code and we will return your call as soon as possible.)

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The Center for Mental Health Services is a component of the Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services.