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Phyllis A. Fazzio Scholarship Application

This is the application form for the Phyllis A. Fazzio Scholarship program at Thom Child and Family Services. The program is designed to encourage and support employee development in two distinct training areas: advanced clinical skills, and leadership and management skills.

The scholarship program is selective and there are no guarantees of funding. Please provide as much detail as possible in your responses to ensure the review committee can make informed decisions.

If you encounter technical issues completing the application, or need further guidance, please contact the Training Department (508-655-5222 x139).

1. Employee Contact Information

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address Provide one where you are easiest to reach. This question requires a valid email address.

Phone NumberUse this format: 111-222-3333

Work
Fax
Mobile

Fax Number

Mobile Phone

URL

2. How many hours* do you work each week? *Applicants must work at least 0.5 FTE, or the equivalent if an hourly employee, to be eligible. This question requires a valid number format.

hrs/week

3. How many years* have you worked in Early Intervention? *Applicants must have worked in the field of Early Intervention for at least 1 year to be eligible.

4. How many years have you worked at this program?

5. Certification for Early Intervention Specialist (CEIS) status:

Space Cell	YES	NO
I have submitted.	YES	NO
I have been awarded.	YES	NO

6. Are you in a position of leadership at your program?If 'Yes", list your job title and/or describe your role in the Comments section.

Comments

7. Do you hold membership in a professional organization? Do you sit on a committee or board of directors? If so, please list the relationship, your role, and your responsibilities.