2009 PATC Scholarship
Deadline Extended to May 8, 2009
2nd Annual Pennsylvania Autism Training Conference (PATC)
“A New Vision for Autism Services: Practical Strategies and Solutions”
Presented by: Bureau of Autism Services, PA DPW
Wednesday through Friday, May 27-29, 2009
Eden Resort Inn & Suites, 222 Eden Road, Lancaster, PA 17601
BAS is pleased to offer scholarships for overnight accommodations for this event.
Who can apply? Accommodations scholarships are available to PA Behavioral Health
Care providers and Direct Service Staff working with children or adults with autism
spectrum disorders, including TSS, BSC, MT, QMRPs, Program Specialists and Case
Managers. Applicants can be new to the field or have a wide range of experiences.
Priority will be given to the Adult Autism Waiver providers.
What are the requirements to qualify for a scholarship?
 Must work for a service provider in Pennsylvania
 Will travel from a distance of more than 100 miles
 Individual applicants must attend all three days of the conference.
 Adult Autism Waiver providers must send a minimum of one staff member to
each day of the conference.
Are scholarships based on financial need? No, scholarships are based on application
responses and will be awarded on a first-come-first-served basis. Priority will be given to
the Adult Autism Waiver providers.
What does the scholarship cover? Scholarships will cover the cost of overnight
accommodations for Wednesday and Thursday evenings at the Days Inn Lancaster, a
short distance from the Eden Resort. For participants traveling over 150 miles, Tuesday
night accommodations are also available. The scholarship does NOT cover the
registration fee.
How soon will recipients be notified? Scholarship recipients will be notified by May
15th via email.
Should I register for the conference before applying for the scholarship? Yes. You
must register online first. Submit a copy of the confirmation email you receive along
with your application. You may also send the application in with your payment. If you
should decide to cancel your registration based on your inability to obtain a
scholarship please deregister online.
How do I apply? Simply complete the application form (on page two) and submit it by
May 5, 2009. See the application form for information on where to submit your
completed form.
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For more information about the conference agenda or registration please visit
www.autisminpa.org or email ra-bastrainings@state.pa.us
2009 PATC Scholarship Application
Applications must be received by May 5, 2008
Inaugural Pennsylvania Autism Training Conference (PATC)
“A New Vision for Autism Services: Practical Strategies and Solutions”
Presented by: Bureau of Autism Services, PA DPW
Wednesday through Friday, May 27-29, 2009
Eden Resort Inn & Suites, 222 Eden Road, Lancaster, PA 17601
Please print all responses clearly. Notification of the decisions made and
additional information will be sent out via the email address you provide.
Submit your application and registration confirmation to:
Bureau of Autism Services, ATTN: PATC Conference SCHOLARSHIPS
State Office Building, 1400 Spring Garden Street, Room 300, Philadelphia, PA 19130
Fax: 215-965-0548
Adult Autism Waiver Providers: Please complete Section A.
Individual Applicants: Please complete Section B.
Individual Applicants applying to share a room: Please complete Section C.
Section A: Adult Autism Waiver Providers
Provider/Agency Name _________________________________________
Contact Person________________________________________________
Email _______________________________________________________
Phone Number ________________________________________________
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Adult Autism Waiver providers may apply for up to one person per day for a
single room or two people per day for a shared room.
Adult Autism Waiver providers applying for scholarships must register a staff
member for all three days of the conference.
All individuals listed must be registered for the conference.
Name: ________________________________________________
Sharing with (if applicable): ___________________________________________
Room requested for (check all that apply): ___Tues. * ___Wed. ___Thurs.
Name: ________________________________________________
Sharing with (if applicable): ___________________________________________
Room requested for (check all that apply): ___Tues.*
___Wed. ___Thurs.
Section A continued on next page
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For more information about the conference agenda or registration please visit
www.autisminpa.org or email ra-bastrainings@state.pa.us
Name: ________________________________________________
Sharing with (if applicable): ___________________________________________
Room requested for (check all that apply): ___Tues.*
___Wed. ___Thurs.
Distance in miles from the agency address to the Eden Resort: _________
To figure out mileage visit www.maps.yahoo.com and enter your address
(under A) and the Eden Resort Inn & Suites address (under B; see above).
To apply for a room on Tuesday individuals must be traveling over 150 miles.
By signing this application I verify that all information provided is accurate. I will provide
all information received to the individuals listed above. A copy of the registration
confirmation for EACH applicant is enclosed.
Printed Name of Person Submitting Form_____________________________________
Signature ________________________________
Section B: Individual Applicants (single applicants)
Individual applicants must attend all three days of the conference.
Your name:____________________________________________________________
Email (required):_______________________________________________________
Phone (with area code): __________________________ ____cell ___work ___home
Please provide your home address. This will be used to verify distance traveled.
Street:__________________________________________________________
City:________________________ State: PA Zip Code: __________________
I work for the following PA Provider Agency: ________________________________
City: ____________________________ County: ______________________________
I am a: ___BSC ___TSS ___QMRP ___ Program Specialist
___ Other (Please specify) ____________________________
I work with: ___individuals under the age of 21 __ adults ages 21+
Distance in miles* from your home address to the Eden Resort: _________
* To figure out mileage visit www.maps.yahoo.com and enter your home address
(under A) and the Eden Resort Inn & Suites address (under B; see above).
To apply for a room on Tuesday individuals must be traveling over 150 miles.
By signing this application I verify that I am registered for all three days of the
conference and that all information provided is accurate. A copy of my registration
confirmation is enclosed.
Signature: ____________________________________________
3
For more information about the conference agenda or registration please visit
www.autisminpa.org or email ra-bastrainings@state.pa.us
Section C: Individual Applicants (sharing a room)
I am applying to share a room with the person identified in Section B.
Individual applicants must attend all three days of the conference.
Your name:____________________________________________________________
Email (required):_______________________________________________________
Phone (with area code): __________________________ ____cell ___work ___home
Please provide your home address. This will be used to verify distance traveled.
Street:__________________________________________________________
City:________________________ State: PA Zip Code: __________________
I work for the following PA Provider Agency: ________________________________
City: ____________________________ County: ______________________________
I am a: ___BSC ___TSS ___QMRP ___ Program Specialist
___ Other (Please specify) ____________________________
I work with: ___individuals under the age of 21 __ adults ages 21+
Distance in miles* from your home address to the Eden Resort: _________
* To figure out mileage visit www.maps.yahoo.com and enter your home address
(under A) and the Eden Resort Inn & Suites address (under B; see above).
To apply for a room on Tuesday individuals must be traveling over 150 miles.
By signing this application I verify that I am registered for all three days of the
conference and that all information provided is accurate. A copy of my registration
confirmation is enclosed.
Signature: ____________________________________________
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For more information about the conference agenda or registration please visit
www.autisminpa.org or email ra-bastrainings@state.pa.us