Family Scholars Program
Family Scholar Application
20132014
FAMILY SCHOLARS PROGRAM ◦ FAMILY SCHOLAR APPLICATION
Thank you for your interest in the AMCHP Family Scholars Program (FSP). The FSP
is a 10-month program geared for family members that want to develop their
leadership skills at the state and/or national level. Through the FSP, family leaders
develop their understanding of Title V, their network, their confidence in advocating on
behalf of Title V and how they can increase family involvement within Title V programs
in their state.
Benefits of participating in the AMCHP Family Scholars Program:
 Gaining a greater understanding of Title V
 Increasing your understanding of AMCHP
 Widening your network of family leaders, parent professionals, maternal and child
health (MCH) and children and youth with special health care needs (CYSHCN)
professionals
 Receiving mentoring from experienced family leaders
 Increasing your knowledge related to key MCH and leadership topics
 Increasing your knowledge related to the MCH Leadership Competencies
 Attending the AMCHP Annual Conference. 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 AMCHP’s annual conference
as Family Scholars. The scholarship covers the cost associated with attending the
conference (conference registration, travel, hotel accommodations, and per diem).
Applicant Requirements: All applicants must submit a completed application, MCH
Leadership Competencies self- pre-assessment, a bio or resume, director form,
supervisor form, and commitment form. With the exception of the MCH Leadership
Competencies, which will be administered electronically, all six documents must be
emailed together for each applicant as Microsoft Word documents. No other formats will
be accepted. Only completed applications submitted via email will be reviewed. The
deadline is close of business (5:00 pm ET) Wednesday, July 17, 2013. Please email
questions and your completed applications to familyscholars@amchp.org.
Family Scholar Applicant Criteria: To determine your eligibility to participate in the
program, please review the section titled, Applying as a Family Scholar, on the program
website on the AMCHP website.
Applicant name:
Home mailing
address:
Job title, if
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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Family Scholars Program
Family Scholar Application
20132014
applicable:
Organization name
and mailing
address:
Email address:
Daytime Phone:
Daytime Fax:
Title V, MCH, or
CYSHCN Director’s
name:
Indicate program
MCH or CYSHCN
State:
Director Email:
Daytime Phone:
Instructions: Please complete the questions below. Use the designated space to
provide your responses. Feel free to use as much space as you need to address each
question as this information is used by the Family Scholars Applicant Review
Committee to assess your application. Note that Title V includes Maternal and Child
Health (MCH) and Children and Youth with Special Health Care Needs (CYSHCN).
Q1: What has been your involvement in Title V? Please address the following
areas in answering this question:
 Describe your involvement and role(s) (e.g., Title V funded program staff, volunteer,
consultant, etc.).
 Responsibilities.
 Leadership experience.
 Experience as a consumer of Title V program for your family (e.g., Medicaid, WIC,
Newborn screening, Clinics, etc.).
A1:
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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Family Scholars Program
Family Scholar Application
20132014
Q2: How are you currently involved with your Title V Program? Please address
the following areas in answering this question:
 Special interests related to the health of women, families and children; how long
have you been involved or engaged in these areas.
 Experience working with or engaging families of diverse background (e.g., age, race,
class, religion, disabilities, rural, urban, etc.) in your state.
A2:
Q3: How do you intend to share information, resources and tools with families
and/or Title V staff in your state if selected as a Scholar?
Q3:
Q4: If you are selected as a Family Scholar, how might Title V support you?
Please address the following areas in answering this question:
 How do you anticipate applying your leadership skills to your position (consultant,
staff, family representative, volunteer, etc.)?
 How would you like your Title V program to support your leadership development?
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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Family Scholars Program
Family Scholar Application
20132014
Q4:
Q5. Indicate if you have engaged in any of the activities listed below by placing an
X in the column to the left. Indicate all of those that apply. Check all that apply. For
activities not listed, enter this information in the row titled Other.
Provide a family perspective (via
Improve planning and policies resulting
materials review, attend program
in services more directly responsive to
meetings, or other avenues)
family needs
Engage in the needs assessment
Improve understanding of programs by
process
legislature, state officials, and the public
Review agency block grant
Increase parent/professional
communication and understanding
Participate on advisory committees
Increase availability of family members
able to participate in training, public
awareness, and policy development
Engage and/or increase family
Establish or strengthen base for a
involvement in Title V programs
strong coalition for change within a
program
Develop family specific tools and/or
Increase responsiveness to Federal
resources for a particular program
requirements
Raise awareness and understanding of
Provide direct, non-medical services,
family issues and needs
information or support to families
Encourage or facilitate collaboration
Develop programs for families
between families/family organizations
and Title V programs
Supervise other family members or
staff employed.
Other:
Q6. Indicate how you would like to benefit from participating in the FSP. Check all
that apply. For benefits not listed, enter this information in the row titled Other.
Broaden my network
Have a better understanding of the MCH
(big) picture
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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Family Scholars Program
Family Scholar Application
Understand emerging issues from the
national level
Obtain a comprehensive view of Title
V/breadth
Develop a cadre of MCH (family)
champions
Develop skills to act as a liaison for
family input and/or engage families
20132014
Develop/increase skill level in the MCH
Leadership Skills
Understand national scope of
MCH/CYSHCN/Title V
Understand my part in Title V
Other:
Personal Statement: Your personal statement helps reviewers better understand your
uniqueness, desire and ability to be a successful family scholar. In the space below,
please describe your interest in becoming an AMCHP Family Scholar. Your personal
statement should address things like:
 How being a Family Scholar would further develop you as a family leader in your
state.
 What is important to you about developing your leadership skills.
 How you expect this program to support your development.
 How you want to develop or expand your leadership capacity.
 How being a Family Scholar would further develop your role in your state Title V
Program.
 Why you want to participate in this program.
 What you want to gain from participating in the Family Scholar Program.
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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Family Scholars Program
Family Scholar Application
20132014
My typed name below indicates I have completed the FSP application.
_____________________________________
Applicant’s Typed Signature
__________________________
Date
Submit a complete application to familyscholars@amchp.org.
The deadline is 5:00 pm Eastern Time, Wednesday, July 17, 2013.
With the exception of the MCH Leadership Competencies, which will be
administered electronically, all documents must be submitted using Microsoft
Word. No other formats will be accepted. A complete application packet is:
1.
2.
3.
4.
5.
6.
Family Scholarship Program Application
MCH Leadership Competencies Self-assessment
Director Form
Supervisor Form
Your resume or bio
Family Scholar Commitment Form
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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