MEMBERSHIP SCHOLARSHIP APPLICATION
The GPAMVO membership scholarship fund was established to help individuals obtain
GPA membership. The following criteria are required for scholarship consideration.
 GPAMVO will not pay membership dues to another organization.
 Awards will be prioritized to members who demonstrate financial need and who
have shown active chapter participation (defined as attendance at the majority of
chapter meetings during the year leading up to this application).
 Awards will be determined according to GPAMVO financial limitations.
 Awards will not exceed National’s fees.
 Recipients are required to become a member of the GPAMVO chapter and are
responsible for paying the chapter fee.
 Awards to a repeat recipient will following a “weaning off” process:
o First award at 100% of membership costs
o Second award at 75% of membership costs
o Third award at 50% of membership costs
o Fourth award at 25% of membership costs
o No fifth awards will be made. At this time the member is ineligible for any
future membership scholarship awards.
 Recipients will agree to attend a minimum of 50% GPAMVO Chapter meetings.
 Award recipients must agree to serve in a volunteer role to support the work of
GPAMVO.
 If scholarship recipients are non-compliant with the above-stated requirements of
their award, they are no longer eligible for any future scholarship awards from
GPAMVO, to include both membership and conference scholarships.
 The GPAMVO Board of Directors has the final decision on all applications.
Please tell us about you:
NAME ________________________________________________________________
POSITION: ____________________________________________________________
ORGANIZATION: _______________________________________________________
ADDRESS: ____________________________________________________________
CITY/STATE/ZIP: _________________________________FAX #:________________
WORK PHONE #:___________________ HOME/CELL PHONE #: ________________
EMAIL ADDRESS: ______________________________________________________
My agency (please check only one):
______ DOES pay for GPA dues
______ DOES NOT pay for GPA dues
Have you received a membership scholarship from GPAMVO in the past?
(Circle only one.)
YES
NO
If yes, in what year? ___________________
Please tell us your reasons for requesting this scholarship.
I have read and agree to the scholarship conditions explained above.
_________________________________________
Signature
Return this form to:
Belinda Orrill, GPAMVO President
Dayton Children’s Hospital
One Children’s Plaza
Dayton, OH 45404
Phone (937) 641-5961; Fax (937) 641-5292
orrillb@childrensdayton.org
________________
Date