Family Scholars Program
Director Form
2010
Thank you for your interest in AMCHP’s Family Scholars Program (FSP). Through support from the
Maternal and Child Health Bureau and Centers for Disease Control and Prevention, AMCHP will award
scholarships to family representatives to attend the AMCHP Annual Conference. Each applicant is
required to submit an FSP Director Form to be completed by a Title V director in their state. Title V
includes Maternal and Child Health (MCH) programs and programs serving Children and Youth with
Special Health Care Needs (CYSHCN).
Your responses to the questions in the form will be considered by the review committee during the
selection of family scholars. A Title V director may nominate no more than two individuals as family
scholars for consideration; however, only one individual will be selected from a state or territory
annually.
Note: After the form has been completed, return the form to the applicant. The applicant will submit
this form as part of the application to AMCHP. If any forms are missing from an applicant’s package,
they will not be reviewed and considered for a scholarship. Only applications submitted by e-mail will be
reviewed. The deadline is December 4, 2009 at 5:00 pm (ET). Please e-mail
familyscholars@amchp.org with any questions.
Title V MCH/CYSHCN Director Contact Information
Name
Title
Degree and/or Credentials
Mailing Address
City/State/Zip Code
Office Phone
Fax
e-mail
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Family Scholars Program
Director Form
2010
Instructions: Please complete the following questions. You may use more than one page to answer each
question. Please note that Title V includes Maternal and Child Health (MCH) and Children and Youth
with Special Health Care Needs (CYSHCN).
1. What potential roles and responsibilities could the nominee contribute to your state
program by participating in the FSP? Check all that apply. If not represented, please list
items under other.
___ Provide a family perspective (via materials review, attention program meetings or other avenues)
___ Engage in the needs-assessment process
___ Review your agencies block grant
___ Participate on advisory committees
___ Engage and/or increase family involvement in Title V programs
___ Develop family-specific tools and/or resources for a particular program
___ Raise awareness and understanding of family issues and needs
___ Encourage or facilitate collaboration between families/family organizations and Title V programs
___ Improve planning and policies resulting in services more directly responsive to family needs
___ Improve understanding of programs by legislature, state officials and the public
___ Increase parent/professional communication and understanding
___ Increase availability of family members able to participate in training, public awareness and policy
development
___ Establish or strengthen base for a strong coalition for change within a program
___ Increase responsiveness to federal requirements
___ Provide direct, non-medical services, information or support to families
___ Develop programs for families
___ Other:
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Family Scholars Program
Director Form
2010
2. How would you like this nominee to benefit by participating in the FSP? Please check all
that apply. If not represented, please list items under other.
___ Broaden their network
___ Understand emerging issues from the national level
___ Obtain a comprehensive view of Title V/breadth
___ Have a better understanding of the MCH (big) picture
___ Develop/increase skill level in the MCH Leadership Skills
___ Understand national scope of MCH/CYSHCN/Title V
___ Develop a cadre of MCH (family) champions
___ Understand their part in Title V
___ Other:
3. Does the applicant have a current role and associated responsibilities with a Title V
program? If so, please describe them.
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Family Scholars Program
Director Form
2010
4. How does the Title V program intend to support the applicant? (e.g. engage as the AMCHP
Family Delegate, engage in Title V training, include on relevant calls, create opportunities
to present to staff and families)
5. What expectations or suggestions do you have for the AMCHP Family Scholarship
Program?
6. The 2009-2012 AMCHP Strategic Plan values family leadership development and
involvement. Is there an opportunity for the state to support the selected Family Scholar to
attend the 2011 AMCHP Annual Conference?
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Family Scholars Program
Director Form
2010
Director’s Support Statement
I have read the expectations related to the program and those outlined in the Applicant Commitment
Form. I am aware of program dates, responsibilities and expectations, and I nominate
___________________ [applicant’s name] as a candidate for my state/territory as an AMCHP Family
Scholar.
If applicable, I agree to permit ____________________________________ [applicant’s name] to take
time from regularly assigned duties to participate in all sessions of the 12-month Family Scholars
Program.
If applicable, I, ____________________________________, [director’s name], agree to support the
applicant’s participation in the FSP. I have discussed this leadership development opportunity with
appropriate organization/agency managers. We have agreed to actively support the applicant’s learning
experience and project activities if (s)he is selected to participate in the program.
My typed name below indicates that I support the application for this individual to the Family Scholars
Program.
_______________________________________
Title V Director’s Signature
__________________________
Date
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