Scholarship
Application
Deadline:
April 1, 2004
(Please
attach conference registration
form)
Name: ____________________________________________________________________________
Organization:_______________________________________________________________________
Mailing
Address:____________________________________________________________________
City:
______________________________State: _________________ Zip:______________________
Phone:
_________________________________Fax:_______________________________________
Email:____________________________________________________________________________
Website:
__________________________________________________________________________
How
did you hear about the conference?
Please
use the space below to briefly tell us about yourself and
your interest in community-based research. This information
will be used for the conference bio list unless you specify
otherwise.
Race/Ethnicity:_
_______________________________________ (Your
response is optional but we are committed to ensuring a diverse
group of participants)
SCHOLARSHIP
QUESTIONS:
1.
Please describe your current work or interest in community-based
research: What do you hope to learn or gain from the conference?
Please provide some ideas on how you might share what you
have learned with others:
2.
Please give an example of an experience in your life that
has stimulated your interest in this work and your participation
in this conference:
3.
Explain your need for a scholarship:
4.
Please provide the name and contact information for someone
who can speak to your work or interest in community issues:
A
limited number of scholarships for "Crossroads: Critical
Issues in Community-Based Research Partnerships" will
be available. The scholarship will cover some or all
of the following: conference registration fee, travel to and
from Hartford, hotel accommodations and per diem. Please be
realistic when deciding your need. There is a set amount in
our scholarship fund, and we prefer to provide support to
as many people as possible. You will
receive notice of monies allocated by April 15, 2004.
I am applying for a (check one):
_____
Full Scholarship (Skip to Travel)
_____ Partial Scholarship (Please answer the following questions)
I am
asking for (please check one or more of the following):
____ Travel
____ Conference Registration
____ Room and Board
TRAVEL
Travel
expenses include flight and transportation to and from the
airport, or mileage. Upon acceptance, we will notify recipients
of amount allotted for travel. Scholarship recipients are
responsible for arranging and paying all travel. Recipients
will receive reimbursement for travel after conference receipts
are submitted. If you have any questions about this process,
please contact us.
ACCOMMODATIONS AND FOOD
Rooms
are being held for conference participants at the Crown
Plaza in downtown Hartford. The Crown Plaza is within
walking distance of Capital Community College, the conference
site. All scholarship recipients will be assigned a roommate
and all reserved rooms are non-smoking. Please fill out the
following questions so that we may better accommodate you
with regard to room assignment.
I want
to room with: ______________________________________________________
Gender
(for room assignments): _____________________________________________
____
I prefer to room with a non-smoker.
Special
Needs: Insert special needs regarding environmental, disability
access & needs, etc.:
__________________________________________________________________________________
All
meals during the conference will be provided with the exception
of one dinner. If you are receiving a full or partial scholarship
for which room and board is covered, you will receive $15.00
to cover the cost of this dinner.
Please
attach conference registration
form
Both scholarship and registration forms are due April 1, 2004
SEND
APPLICATIONS TO:
Institute
for Community Research
ATTN:
Crossroads Scholarship
2 Hartford Square West, Suite 100
Hartford, CT 06106
E-Mail: scholarships@icrweb.org
Fax: (860) 278-2141
Questions?
Contact Maryann Abbott, (860) 278-2044 ext. 286
or email scholarships@icrweb.org
FOR OFFICE USE ONLY
____________
Travel
Amount Received $_____________
____________
Room and Board
Contacted by: ___________________________
____________
Registration
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