Washington State Scholarship InformationRegion 10 Opioid Summit

August 7 and 8, 2019Vancouver Hilton Conference Center

Vancouver, WAIntroduction and Purpose

The Washington State Health Care Authority (HCA) encourages providers to cover the costs of employees to attend the Region 10 Opioid Summit. This represents the provider’s commitment to maintain, support, and train individuals on the best practices and research available to address opiate overdose and opioid use disorder. The purpose of this scholarship is to support individuals who do not financial resources to attend the Summit.

Application Criteria

To be considered for a scholarship from Washington, the applicant must be employed by a provider that is under contract with the Washington Care Authority (HCA) or a subcontractor of a HCA partner (such as Behavioral Health Organizations, Administrative Service Organizations, Counties, Washington Federal Recognized Tribes, Therapeutic Courts, Prevention Coalitions, Schools, or University of Washington’s Alcohol and Drug Abuse Institute) that is providing services designed to prevention or reduce opioid use in Washington. Scholarships are also available to prevention partnerships such as those that are part of Drug Free Communities.  Other prevention coalitions and prevention partners are welcome to apply. Priority will be given to those professionals that are currently providing services designed to prevent or reduce opioid use disorder in Washington.  Applicants must also live in Washington State at the time of the application and Summit date.

Applications must be accompanied by a letter from the provider stating they are unable to cover the cost of participation at the summit.

Applicants are encouraged to ask one or more sources other than their employer for financial support such as their Behavioral Health Organizations (BHO), United Way, or other entities for some or all of the costs associated with attending the Summit (lodging, travel, food, etc).

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Applicants receiving the scholarship are encouraged to share information gained while attending the Summit. Information gained at the Summit may be shared at community forums, provider agencies, prevention coalitions, clubhouse, drop-in center, 12 step programs, or other recovery venue.

All applications must be completed in full or the scholarship materials will be returned.

Expectations as a scholarship recipient: you are expected to attend the Summit each day and participate fully in the Summit by attending the keynote presentations and workshops, failure to do so may disqualify you for future scholarship opportunities.

Cancelations -must submit notice immediately if you are unable to attend once scholarship has been awarded or risk disqualification for future scholarship opportunities.

No shows are automatically disqualified for a scholarship the following year.

Submit applications to Earl Long via fax at 360-763-4702 or via email at HCAR10SummitRequest2019@hca.wa.gov no later than June, 20, 2019. You will be notified via email by Friday, July 5, 2019 regarding your scholarship status. If the forms are incomplete or not completed correctly the application can’t be accepted.

Due to the large number of applications submitted late or incomplete applications will NOT be considered.

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Washington State Scholarship ApplicationRegion 10 Opioid Summit

All information must be completed and submitted by:5 P.M Thursday, June 20, 2019

Please note all documents must be signed and complete or your application cannot be accepted.

First Name:___________________________________________________________

Last Name:___________________________________________________________

Name as appears on the nametag:_________________________________________

Applicant’s Address: ________________________________________________________

City: __________________________ State: _____________Zip:_________

Phone Number: _____________________________

E-mail Address:____________________________

Employer: __________________________________________

Employer’s Address: ________________________________________________________

City: __________________________ State: _____________Zip:_________

Phone Number: _____________________________

E-mail Address:____________________________

Employment Level:

Student/Intern Management Peer Support

Administrative Director/Executive Consumer

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Professional Management

Retired Volunteer

Other; Specify: ____________________

Primary Employment Type(s) - mark all that apply

Behavioral Health Professional - Prevention

Behavioral Health Professional - Intervention

Behavioral Health Professional - Treatment

Behavioral Health Professional - Recovery

Syringe Exchange employee

First Responder - Emergency Medical

First Responder - Law Enforcement

Criminal Justice (Court, Attorney, Public Defender)

Educational Professional

Social Worker

Medication Assisted Treatment provider

Medical Professional - Physician

Medical Professional - Physician Assistant

Medical Professional - Nurse

Medical Professional - Care Manager

Other Social Services Professional (Developmental Disabilities, Youth Services, Family Services, Child Welfare)

Juvenile Justice Services

Retired

Volunteer

How did you hear about the Region 10 Opioid Summit?Save the date Email Co-Occurring Disorders Website DSHS/BHSIA Website CASAT or CASAP Website Referral Other:________________________

Would you like to receive future emails about conferences?Yes No

Dietary Restrictions: Vegetarian VeganDairy Free Gluten FreeNut Free NA

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Note: there may not be an alternative for every item served but dietary restrictions will be considered in meal planning. If your diet is severely restrictive you may want to consider bringing some of your own food as the conference committee cannot be responsible to ensure your dietary needs are met.

Accommodations (Please specify only ADA needs (sign language interpreter, wheelchair access, etc.) _____________________________________________________________________________

I agree to allow sponsors and affiliates of this Summit to contact me regarding news and announcements at my email address provided.

Yes No

Please Check Requested Resources:Lodging Food reimbursement Ground transportation

reimbursementTransportation Gray Hound Bus Registration Stipend

Note: Air transportation is not eligible for reimbursement.

In requesting lodging please be aware that cancelation is required to avoid the expense of that room. Each individual requesting lodging is expected to utilize that room for the nights requested or provide timely cancelation.

I would like to receive Continuing Education Hours (CEHs.) Yes No

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Have you attached documentation regarding your employer’s contribution to your costs for attending the Summit?

Yes No

Have you asked another resource for funding?BHO United Way Family Provider agency

other

Photo Release By registering for the 2019 Regional Ten Opioid Summit, I hereby agree to the use of my photograph, name and/or likeness in any recorded sessions.

Please check that you have read and understand the photo release policy.

Please sign that you have read and understand your responsibility as a scholarship awardee:

Signature: __________________________________________________________________

Date: _____________________________________

If you have questions about the application, please contact Earl Long, Opioid Summit Chairperson, at 360 791-0178 or via email at HCAR10SummitRequest2019@hca.wa.gov.

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