19th Annual Crisis Intervention Conference
Thursday & Friday, October 1-2, 2015
Kalahari Resort & Convention Center – Wisconsin Dells, WI
Consumer Scholarship Application
To apply, complete the information requested and send it so that we receive it no later than Friday, August 28, 2015.
Remember: DO NOT REGISTER for the conference if you are submitting a scholarship
application. If you are awarded a scholarship, instructions will be sent in an email with
specific scholarship registration information on September 4th.
To submit your scholarship application, do one of three things:
1. Email to: UWSPCE-Conferences@uwsp.edu. Please indicate Crisis Scholarship Application in the subject line
of the email.
2. Mail to:
UWSP Continuing Education & Outreach
2100 Main Street, 032 Main Building
Stevens Point, WI 54481
3. Fax to: 715-346-4045
Scholarships are limited to conference registration fee and one night’s lodging. Scholarship recipients are responsible for
transportation to and from the conference.
If it’s determined you don’t meet the criteria to be awarded a Consumer Scholarship, you will be notified as soon as
possible so you can register through the normal process.
Scholarships are considered on a first-come, first-served basis if you meet all criteria.
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: _______________________________________________________________
Telephone: ___________________________________________________________________
E-Mail: ______________________________________________________________________
Have you attended a previous Crisis Intervention Conference?
- Years________
Have you received previous scholarships?
Are you a consumer of mental health or substance use disorder services?
1
Complete information on both pages
Scholarship Funding Requested:
____ one night’s lodging & conference registration
____ conference registration only
Please answer the following questions (attach a separate piece of paper if needed):
1. Why do you wish to attend the conference?
2. How will you share the information obtained at this conference with local or statewide consumer groups?
3. Are you currently involved in any programs or activities in the crisis intervention field? Yes
yes, please describe.
By accepting this scholarship, I agree to help with staffing needs at the conference, and to utilize and share this knowledge
with my peers and others.
_________________________________
Applicant Signature
________________
Date
2
Complete information on both pages