THE MENTAL HEALTH AWARENESS COALITION
MICHELLE CUSSEAUX MEMORIAL SCHOLARSHIP
Application Form
Deadline: October 16, 2015
The purpose of the Mental Health Awareness Coalition Scholarship is to honor the work of Dr. Max Dine & Marilyn Racer for their many years of dedicated service on behalf of the mental health community. Their advocacy efforts have raised awareness and positively impacted treatment and increased opportunities for persons living with mental illness in Arizona and throughout the United States. The name of this scholarship is named to honor the memory of Michelle Cusseaux to help enrich the lives of others living with mental illness. The Mental Health Awareness Coalition Scholarship assists adults diagnosed with a mental illness in gaining educational opportunities for life enrichment, employment and higher education. Applications are due October 16, 2015, and scholarship recipients will be announced in the beginning of 2016 for the spring semester.
One scholarship in the amount of $500 will be awarded to one recipient per semester per year or One computer will be given to one recipient.
PRINT neatly or TYPE your responses using black ink.
Check the box below for the Scholarship(s) for which you wish to apply. Only one Scholarship will be awarded to you if you are selected.
Life Enrichment (eg. computer, take an art or music class, YMCA membership, etc.)
Employment Courses (eg. GED, Vocational)
College Degree/Vocational Certificate
Other:
(Please give explanation/description)
Applicant’s General Information
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(First Name) (MI) (Last Name)
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(Mailing Address)
______Arizona ______
(City) (Zip Code)
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(Phone) (Email Address)
Applicant’s Certification and Signature:
I certify that I am a resident of the state of Arizona, 18+ years of age and that all the information provided in this application form and attached documents are true and complete to the best of my knowledge.
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Print Your Name Sign Your Name
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Date
If you have a Guardian, it is desired but not required to have them sign below:
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Guardian (Print) Guardian (Sign)
______
Date
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Complete and submit the Application Form with the following required documents:
√ A written statement of not more than one (1) page in length sharing your reasons for applying for a MENTAL HEALTH AWARENESS COALITION SCHOLARSHIP and your experience as a person living with a mental illness or behavioral health disorder and/or your involvement in the mental health community.
Mail, Scan/Email, or Fax application and required documents to:
MAIL: Mental Health Awareness Coalition Scholarship Committee
c/o Robin Quiroz
Arizona Behavioral Health Corporation
1406 N. 2nd Street
Phoenix, Arizona 85004
Email:
FAX: 602.712.9222 x205