Family Scholars Program
Family Scholar Application
20122013
Thank you for your interest in the FPS. To determine eligibility, please review the section
titled, Applying as a Family Scholar, on the program website on the AMCHP website.
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).
All applicants must submit a completed application and a bio or resume, as well as the Director
Form, Supervisor form and Commitment Form. All five 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 11, 2012. Please email questions and your
completed applications to familyscholars@amchp.org.
Applicant name:
Home mailing
address:
Job title, if
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:
What is/are the age
of your
child(ren)/family
member(s)?
If applicable, What
type(s) of
disability(ies) do they
have?
INSTRUCTIONS: Please complete the questions on the next page. Provide your response in the
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
20122013
row after each question. Use as much space as you need to address each question. You may
use more than one page to complete your responses to the questions listed. Note that Title V
includes Maternal and Child Health (MCH) and Children and Youth with Special Health Care
Needs (CYSHCN).
Along with your application, submit your resume or bio. Information to include: education, work,
volunteer, and leadership experience.
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:
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 would being a Family Scholar further develop your role in your state Title V
Program? Please address the following areas in answering this question:
 Why do you want to participate in this program?
 What do you want to gain from participating in the Family Scholar Program?
 How would you like to contribute to the program(s) in your state as a result of participating
in this program? Please note at least three ideas for involvement.
A3:
Q4: How would being a Family Scholar further develop you as a family leader in your
state? Please address the following in answering this question:
 What is important to you about leadership development?
 How do you expect this program to support your development?
 Describe how you want to develop or expand your leadership.
A4:
Q5: 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?
A5:
Q6: 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.)?
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
20122013
 How would you like your Title V program to support your leadership development?
A6:
Q7. 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 materials
review, attend program meetings, or other
avenues)
Engage in the needs assessment process
Review agency 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
Supervise other family members or staff
employed.
Other:
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
Q8. 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
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
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
Understand my part in Title V
Other:
My typed name below indicates I have completed the FSP application.
_______________________________________
Applicant’s Typed Signature
__________________________
Date
Submit a complete application to familyscholars@amchp.org.
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
20122013
The deadline is 5:00 pm Eastern Time, Wednesday, July 11, 2012.
All five documents must be submitted using Microsoft Word.
No other formats will be accepted. A complete application packet is:
1. Family Scholarship Program Application
2. Director Form
3. Supervisor Form
4. Your resume or bio
5. Family Scholar Commitment Form
For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).
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