CPF Conference Scholarship Application for Affiliates

Affiliate Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Information

The primary contact listed below will be responsible for award status notifications, coordinating attendees from the affiliate, and submitting any follow up documentation.

Affiliate Primary Contact

First

Last

Primary Contact Phone

Primary Contact Email

Attendee Information

Layout

Attendee #1 Name

First

Last

Attendee #1 Profession

Attendee #1 Email

Attendee #1: Did you attend the 2022 conference?

Attendee #1: Are you formally trained in HINE?

Attendee #1: Do you wish to attend the 2023 HINE training?

Attendee #1 Shirt Size

Attendee #2 Name

First

Last

Attendee #2 Profession

Attendee #2 Email

Attendee #2: Did you attend the 2022 conference?

Attendee #2: Are you formally trained in HINE?

Attendee #2: Do you wish to attend the 2023 HINE training?

Attendee #2 Shirt Size

Layout

Attendee #3 Name

First

Last

Attendee #3 Profession

Attendee #3 Email

Attendee #3: Did you attend the 2022 conference?

Attendee #3: Are you formally trained in HINE?

Attendee #3: Do you wish to attend the 2023 HINE training?

Attendee #3 Shirt Size

Attendee #4 Name

First

Last

Attendee #4 Profession

Attendee #4 Email

Attendee #4: Did you attend the 2022 conference?

Attendee #4: Are you formally trained in HINE?

Attendee #4: Do you wish to attend the 2023 HINE training?

Attendee #4 Shirt Size

Additional Information

Please respond to the following questions.

Explain your affiliate's work in the area of early intervention and treatment of young children.

Explain why your affiliate wants to attend the conference.

Will others from your affiliate be attending that are not on this application and their attendance will be supported by the affiliate? Please note their names and emails below.

We would love to include them in some of the activities!

Commitment Agreement

Please check the box to confirm your commitment.

The individuals list on this application will be able to commit to 3-4 hours of pre-conference homework.

The individuals listed on this application will be able to meet monthly for a virtual post-conference implementation workgroup for one-year.

Comments

Budget Request

Use this section to identify any anticipated expenses related to travel, hotel, and food. The conference registration fees will be paid directly to CPF but also should be noted to reflect the number of people you are requesting to attend. The maximum allotment is $2,000 per person total. Note: Transportation, hotel and food will be reimbursed post-conference. Receipts will be required for all reimbursements.

Transportation

Airfare, Driving, etc

Hotel

The designated hotel for the conference is estimated at $130 per night.

Food

Food will be reimbursed up to $50 per person per day.

Conference Registration

The cost for registration is $450 per person. UCP will pay this portion directly and attendees will be provided a code to use when registering.

Total Amount Requested

Budget Justification

Please provide a full description of how the cost were determined.

By typing my name below, I certify that my answers are true and complete to the best of my knowledge.