CADCA's 2021 National Leadership Forum Adult Scholarship Application

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SUBMISSION DEADLINE: 12 Noon EDT FRIDAY, October 30, 2020

The application for the 2021 Virtual National Leadership Forum SAMHSA Scholarship program is now open. Scholarships will cover the applicable registration fee. All applications must be submitted online and are due no later than 12 Noon EDT FRIDAY, October 30, 2020 and must be fully completed in order to be considered.

For any questions, email Kahlee Yeldell at kyeldell@cadca.org.

IMPORTANT RULES TO READ:

-All submitters will be notified by email to the addresses provided on the application form.
-Once recipients are selected, the scholarship cannot be transferred to another individual within your coalition if the original recipient is now unable to attend.
-The scholarship cannot be divided among other members of the coalition.
-A scholarship from another year cannot be applied as a scholarship for this year.
-A scholarship for one person in the coalition does not mean everyone at the coalition who applied also received a scholarship.
-Scholarship recipients must attend the entirety of Forum (Monday through Thursday afternoon).
-Adult scholarship recipients may be needed to serve as session monitors for 1-2 training session at Forum.

Notifications will be emailed out the week of November 1, 2020 .

Adult Application Contact Information

Adult Applicant First Name *

Please use proper case.

Adult Applicant Last Name *

Please use proper case.

Adult Applicant's Job Title *

Adult Applicant Coalition or Organization Name *

Please use proper case.

Adult Applicant Address1 *

Please use proper case.

Adult Applicant Address2

Please use proper case.

Adult Applicant City *

Please use proper case.

Adult Applicant State Code *

Please use proper case.

Adult Applicant's US Territory Code

Please only select this option if you reside in American Somoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico or the US Virgin Islands.

Adult Applicant Zip Code *

Please use proper case.

Adult Applicant's Country *

Please type your country in proper case. For example, United States.

Adult Applicant's Phone Number *

Please provide the phone number in the following format: (XXX) XXX-XXXX

Adult Applicant's Email Address *

Please double check for the correct spelling of your email. This will be the main form of communication regarding your application.

Email Address From Someone Else In Your Coalition/Organization *

Please provide an email address (different) from yours. We want to make sure that we are able to contact you.

Adult Applicant's Gender *

Male

Female

Adult Applicant's Age *

Adult Applicant's Ethnicity *

American Indian or Alaskan Indian

Asian or Pacific Islander

Black or African American

White (Non-Hispanic)

Hispanic or Latino

Other:

Required

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