MAIT Scholarship Application

All requests are confidential and will be reviewed initially only by the MAIT Administrator.
Qualified applications will be forwarded to the Scholarship Committee for review. You will be notified of the Committee’s decision to move to the interview step within 2 weeks.

Questions or concerns should be directed to the MAIT Administrator: admin@imagoma.org
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Email *
Date of application: *
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DD
/
YYYY
First/Last Name *
City and State You Reside? *
Phone? *
Active MAIT Member? *
 Racial/Ethnic Identity: *
Current Employment/School: *
Clinical Training you wish to attend & when:: *

Why do you want this training and how do you envision using it?

 *

My household income is in the following range:

 *

My household income supports __?__ no. of people

 *
If awarded this Scholarship, I agree to be an active participant in the MAIT community for the 2-year training duration. *
A copy of your responses will be emailed to the address you provided.
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