Wisconsin Peer Recovery Conference
December 8th and 9th, 2015 Hotel Mead, Wisconsin Rapids
Lodging Scholarship Application
To apply, complete the information requested below and mail (or email) it so it is received no later than
November 17th, 2015. For specific questions, contact Aaron Rasch at 608-787-1111.
Mail to:
Aaron Rasch
4439 Mormon Coulee Road
La Crosse, WI 54601
OR
Email to: aaron.rasch@ilresources.org
Lodging Scholarship notifications will be made beginning November 20th, 2015. If you apply but do not receive
a scholarship, Hotel Mead will honor the room block rate of $82 if you still wish to attend. Scholarships are
non-transferrable.
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: _______________________________________________________________
Telephone: ___________________________________________________________________
E-Mail: ______________________________________________________________________
Are you utilizing this conference for employment purposes?
Is this conference relevant to your current employment
Are you interested in on-going mental health or addiction recovery advocacy efforts
If yes, can we contact you for future advocacy and outreach activities related to recovery
Are you a Certified Peer Specialist
Funding requested:
lodging for December 8th, 2015 (must reside at least 50 miles from Conference location)
Hotel Mead, 451 East Grand Avenue, Wisconsin Rapids
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Complete information on both pages
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 groups?
3. What are the specific issues, related to mental health or addiction recovery, in which you are most
interested?
4. Are you currently involved in any programs or activities in the mental health/substance abuse field?
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
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Complete information on both pages