12th Annual
Conference on Crimes Against Women
May 22-25, 2017
Scholarship Application

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Which scholarship are you interested in? *


 
If submitting for the Texas Team or Matching scholarships, please list the name(s) of the other applicant(s) you are submitting with. *Note: each group/team member will need to submit their own application.

 
If applying for the (non Texas) Team of 2 or Matching Scholarship: Which state do you work in? (Only accepting applications from South Dakota) *


 
Applicant Information

 
Name of Applicant: *

 
Applicant's Position: *

 
Applicant's Organization: *

 
Street Address, City, State & Zip Code: *

 
Phone Number:

 
How long have you served at your current organization? *

(in years)
 
How long have you served in your current role? *

(in years)
 
What are the duties of your role, and how will this conference help you to better perform those duties? *

 
If you were to attend CCAW, with approximately how many co-workers or others would you be able to "share" or "teach" what you gained from the conference? *

 
Please include the reason(s) you require financial support in order to attend the conference. Please include what funding you would require to attend (Registration, Hotel, Travel, etc.). *

 
Have you attended the conference before? *

     
 
Have you received a scholarship anytime in the past 3 years to attend the conference? *


 
Organization Information

 
Name of organization: *

 
Name and Title of head of organization: *

 
Work Street address, City, State & Zip Code: *

 
Type of Organization *


 
How would you describe your service area?


 
How did you hear about us? *

 
Statement of Commitment
Please indicate your acceptance of the responsibilities detailed below by selecting "I accept" or "I don't accept." Please note we have limited scholarship funds, and this is a competitive process. Completing this application does not guarantee funding. *

- Commit to an active role and attend all available sessions of the Conference
- Submit required reports and/or surveys as requested. Pre and post surveys will be requested as dictated by our scholarship funders.
- Submit a press release to a local news outlet announcing the award (CCAW will provide recipient with a sample template if requested).
     
 
I agree that if I am offered a scholarship and accept, I will be responsible for reimbursing CCAW for the cost of registration ($460) and hotel ($673.12) and any travel expenses already incurred if I am unable to attend and do not provide notice or a replacement in my absence before April 1, 2017.

Please read carefully and respond.
     
 
Full name of applicant and date: *

Thank you for applying for a scholarship to attend the
2017 Conference on Crimes Against Women.

Please allow 6 weeks for processing. If you are applying as a group, please have each team member submit an individual application. 

Questions? Please contact Sarah Stubblefield at sstubblefield@genesishelter.org

To visit the Conference website
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