East Dayton AWARE Project MENTAL HEALTH FIRST AID INSTRUCTOR SCHOLARSHIP APPLICATION Mental Health First Aid (MHFA) is an in-person training that teaches individuals how to help people who are developing a mental illness or who are in a mental health crisis. For more information about MHFA, please go to www.mentalhealthfirstaid.org. The ADAMHS Board for Montgomery County wishes to support MHFA trainings in Montgomery County. As such, we are looking for qualified individuals to become certified MHFA Instructors. This training scholarship process has been implemented to identify appropriate candidates who are committed to providing MHFA trainings in conjunction with the East Dayton AWARE Project (EDAP), an initiative that will conduct MHFA trainings on the east-side of Dayton to individuals who live, work, worship, or serve in zip code areas 45403 and 45410. The scholarship will pay for all registration fees and travel costs related to the Adult MHFA Instructor training. To apply for a scholarship, please complete the following application. All applications are due no later than November 20, 2015 by 5:00 PM and should be sent to ahoff@mcadamhs.org. Late applications will not be accepted. Name Organization (if applicable) Title (if applicable) Street Address City, State, Zip Code Phone Number E-Mail Address 1 Respond to the following questions as fully and succinctly as possible. Why do you want to become a Mental Health First Aid Instructor? What are your experiences and qualifications related to mental health? What are your experiences and qualifications related to giving oral presentations? Stipends After becoming a certified MHFA Instructor, scholarship recipients will receive $150 per completed MHFA training conducted on behalf of EDAP during the first year of the program. This stipend amount may increase in subsequent years. Stipends will be waived for individuals who are being paid by an employer during the time they spend conducting MHFA trainings on behalf of EDAP. Expectations Scholarship recipients will be required to attend a five-day MHFA Instructor Training which will be held December 7-11, 2015 in the Dayton, Ohio, area. Additional meetings will be held on an as needed basis with attendance being required. Scholarship recipients will also be required to provide a minimum of four complete MHFA trainings per calendar year for three years under the supervision of the EDAP Project Coordinator and will not provide this training for charge until the three-year grant is completed. Equal Opportunity Policy It is the policy of the ADAMHS Board for Montgomery County to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. 2 Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am selected to receive a scholarship, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal from receipt of future training scholarships. If I receive a scholarship, I agree to attend the entirety of the training. I agree to provide a minimum of four complete MHFA trainings per calendar year for three years under the supervision of the EDAP Project Coordinator. I also agree that I will not provide this training for charge until after the three-year grant is completed. Applicant Name (printed) Applicant Signature Date Supervisor Commitment If the applicant will be receiving payment by an employer during their participation in EDAP, the applicant’s employer must support the applicant’s application and full participation. If this is not the case, please write “N/A” on the lines below. My signature verifies that I am the direct supervisor of the applicant listed on this application and that I fully support the applicant’s attendance at the December 7-11, 2015 MHFA Instructor training and all future MHFA meetings and trainings the applicant attends on behalf of EDAP. Supervisor Name (printed) Supervisor Signature Date 3 EDAP Travel Policy This policy is intended to serve as a guide for the proper processing of various travel activities. Scholarship Recipients are expected to exercise good judgment and make expenditures in a prudent manner, consistent with the highest ethical standards and the need to expend public funds in a frugal and economic manner. A. Registration fees, airfare, and lodging will be paid for in advance by the ADAMHS Board for Montgomery County. These items will require authorization by the Board prior to obligating the Board to any related expenses and will follow all policy guidelines established in this document. B. Scholarship Recipients will receive reimbursement for authorized expenses incurred while traveling, provided the policy has been followed as specified in this document. Expenses shall be reimbursed following submission of true and actual receipts which document the prior authorized training. Scholarship Recipients must submit to ADAMHS an invoice and all original receipts verifying expense amounts and purpose. Receipts must be itemized. Non-training related items are not subject to reimbursement. Expenses, which are approved, shall be reimbursed in the following manner. Mileage: Scholarship Recipients shall be reimbursed for actual miles traveled, at the mileage rate approved by the Montgomery County Commissioners at the time of travel, when using their personal vehicle. Such payment is considered to be total reimbursement for all vehicle-related expenses (e.g., fuel, oil, insurance, depreciation, etc.). A detailed account of actual miles traveled showing the starting point, destination, and total miles traveled, must be provided. A template for invoicing for mileage expenses will be provided. Parking and Tolls: Charges incurred for parking at the destination, and any highway tolls are reimbursable at the actual amount. Meals: Expenses incurred for meals when overnight travel is required are reimbursed consistent with Montgomery County policy. The maximum meal reimbursement for authorized County travel is $50 per day. All requests for meal reimbursement must be accompanied by properly executed receipts. There is no reimbursement for any meals which are included as part of the program/event package, even if the attendee chooses to forego the provided meal. Meals for Partial Day Travel: If the travel occurs over a partial day, only the portion of the day in which travel actually occurs will be considered for the per diem rate. For example, if travel concludes by 6:00 PM, dinner is not reimbursable. Motel and Hotel Expenses: Expenses covering the actual cost of a motel or hotel room (single room rate) will be paid for, in advance, when the Scholarship Recipient travels out of Montgomery County, and such travel requires an overnight stay. Original receipts must be submitted upon completion of the training. 4 C. D. Conference Sponsored Motel and Hotel Expenses: The Board will pay for the lowest available single occupancy conference rate for on-site lodging at the MHFA Instructor training program. Alternative to Motel or Hotel Lodging: Should the Scholarship Recipient stay with a friend or family member in lieu of a motel or hotel room, the Board will reimburse the Scholarship Recipient $15.00 per day as an incentive to reduce lodging costs. Air and Other Common Carrier Travel: Travel by air, bus, train or other common carriers shall be undertaken at the lowest rate reasonably available. ADAMHS will coordinate airfare and other common carrier travel details in conjunction with the Scholarship Recipient and will pay for these expenses in advance. ADAMHS WILL NOT REIMBURSE FOR FIRST CLASS TRAVEL. If a Scholarship Recipient chooses to travel at any rate higher than the lowest (coach/economy rate) s/he must personally pay the difference in costs. Alternatives to Common Carriers: As an alternative to common carrier, the Scholarship Recipient may choose to use his or her privately owned automobile for travel and be reimbursed in accordance with current Montgomery County reimbursement policies. The Board reserves the right to prescribe the most appropriate and economical method of travel based upon the circumstances of each individual case. Registration Fees: Registration fees for MHFA Instructor training will be paid for by ADAMHS in advance. Recipients must submit verification of their attendance at the full MHFA Instructor training to the EDAP Project Coordinator at the completion of the training. Non-Reimbursable Expenses: Expenses which will not be reimbursed include the following. 1. Dry cleaning 2. Cosmetics/personal needs 3. Parking tickets, traffic fines, and related costs 4. Privately owned vehicle repairs 5. Alcoholic beverages 6. Gratuities which exceed standard practice 7. Entertainment 8. Personal telephone calls 9. Snacks Receipts are required for the following: 1. Air, bus, and train travel 2. Taxi, limousine and airport shuttle fares 3. Pre-authorized automobile rentals 4. Hotel and motel rooms, including taxes 5. Parking fees greater than $1.00 6. Training registration fee 5 E. F. G. H. Receipts are not required for the following: 1. Toll road charges 2. Parking fees equal to or less than $1.00 3. Mileage on privately owned vehicle [however, the Board may verify mileage claims by any reasonable means, including requiring statements of actual odometer readings and inspection of vehicle odometers]. Requests for reimbursement must be submitted no later than 60 calendar days after incurring the expense, or no later than 30 calendar days after the end of the fiscal year, whichever occurs first, or the receipt of an invoice for such expense, whichever is later. Any request submitted after such period is not eligible for reimbursement. Scholarship Recipients who falsify any claimed expense may be subject to appropriate legal action up to and including prosecution for theft. Notwithstanding the above, the Board retains the authority to disapprove any expense, including [but not limited to] mileage, motel rooms, and meals which the Board determines is inappropriate, insufficiently documented, excessive, or not in accordance with this policy. 6