Annual Conference Scholarship Application Thank you for applying for a scholarship to attend the NAMI Vermont 2023 Conference: Together for Mental Health! Check your email for confirmation of your application. Are you a member of NAMI Vermont?(Required) Yes No Do you plan to attend the NAMI Vermont Annual Business Meeting immediately following the conference (4–5 p.m.)?(Required) Yes No The NAMI Vermont Annual Business Meeting is an opportunity for NAMI Vermont members to vote on the Slate of Candidates for the Board of Directors and hear key highlights about the organization. Only members may vote, but anyone is welcome to attend. Become a member at namivt.org/membership.Name(Required) First Last Organization/Affiliation Email(Required) Phone(Required)Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Which morning workshop would you like to attend?(Required) Dr. Xavier Amador: LEAP to Help People With Serious Mental Illness Kristine Reynolds: Understanding Resilience Perspectives on Mental Health: Lived Experience Stories Panel Please choose one. Visit namivt.org/conference for descriptions of each workshop and presenter.Which afternoon workshop would you like to attend?(Required) Dayna Altman: Bake It Till You Make It! Kurt White: Breakthrough? Psychedelic Psychotherapies, Interventional Psychiatry, and Other New and Prospective Treatments for Mental Health Challenges Frank Osten: Exploring Rural LGBTQIA+ Health Access and Justice Please choose one. Visit namivt.org/conference for descriptions of each workshop and presenter.Are you requesting CEUs (Continuing Education Units) for this conference?(Required) No Yes—I would like CEUs as a Licensed Clinical Mental Health Counselor Yes—I would like CEUs as a Social Worker Yes—I would like CEUs as a Recovery Coach (Certified or Seeking Certification) Last 4 Digits of Social Security Number(Required)Please enter a number from 0000 to 9999.This identification is required for us to process your CEUs as a Licensed Clinical Mental Health Counselor.NASW ID Number(Required)Please enter a number from 0000 to 9999.This identification is required for us to process your CEUs as a Social Worker.Please write a paragraph or two describing why you would like to attend the NAMI Vermont 2023 Conference and what you hope to achieve by attending.(Required)Will you need any accommodations? If so, please describe them. I would like to receive the NAMI Vermont biweekly e-newsletter. 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