DEPARTMENT OF BEHAVIORAL HEALTH APPLICATION FOR WRAP AROUND THE WORLD 2015 SCHOLARSHIP     

      1.      Please indicate your Ward: ___(Ward 1) ___(Ward 2) ____(Ward 3) ____(Ward 4) ___(Ward 5) ___(Ward 6) ____(Ward 7) ___(Ward 8)

      2.     Applicant Name:__________________________________________________________

      3.     Street Address: (if not affiliated with an organization): ________________________________________________________________

      4.     City/State/ZIP:____________________________________________________

      5.     Organization Name:__________________________________________________________

      6.     Organization Address: ________________________________________________________________

      7.     City/State/ZIP:____________________________________________________

      8.     Daytime Phone No. (______)_________________

      9.     Have you attended a WRAP Around the World Conference in the past? ____No  ____Yes (what year?________________)

    10.     Have you received a DBH scholarship in the past? ____Yes _____No

    (what year?________________)

11.   Are you a WRAP Facilitator?  ______Yes  ______No

Please answer the following questions - and use more paper if needed.

1. Describe why you should be considered for the Wrap Around The World Scholarship;

2. If applicable, briefly describe your involvement and/or contributions as a WRAP Facilitator;

3. If awarded a scholarship, how do you plan to utilize the information from the conference?