Alternatives Conference 2014

Creating the Future: Change, Challenge, Opportunity

October 21 – 26, 2014Orlando, Florida

CAC Application for Conference Attendance and Travel

Application deadline: July 10, 2014

The Kansas Consumer Advisory Council for Adult Mental Health, Inc. (CAC) through a contract line item adjustment approval with Kansas Department on Aging and Disability Services, is providing financial support to CAC Board Of Directorsand Kansas Consumers who wish to participate in the Annual National Consumer Conference, Alternatives, sponsored by Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of this funding is to allow Kansas consumers the opportunity to experience, grow, and learn from their peers across the United States, and to find new ways to focus on recovery. Please Note: To be eligible for this funding, a completed application must be received by U.S. Mail, postmarked on or before the deadline of July 10, 2014. NO FAXED, HAND DELIVERED, OR E-MAILED SUBISSIONS WILL BE ACCEPTED.

Please PRINT the following information as you would like it to appear on the participant list. PLEASE DO NOT USE ACRONYMS.
Contact Information
Name / Title
Organization/Agency
Residential Address
City / State / Zip
Telephone / ( ) / Fax / ( ) / Alternate Telephone / ( )
E-mail / Alternate E-Mail
Are you an U. S. citizen (please circle one) Yes or No
Date Of Birth (REQUIRED)
Emergency Contact Information
Name / Relationship
Organization/Agency
Home Mailing Address
City / State / Zip
Home Telephone / ( ) / Work Telephone / ( ) / Emergency Telephone / ( )
Financial Support
Have you received CAC support to attend a national conference in the past?
No / Yes / If yes, what conference and year?

Additional Information

On a separate piece of paper (typed please), please provide the review committee with your answers to the following questions. Do not put your name on any of these additional sheets of paper, or identify yourself in any of the questions.

  1. Why do you want to attend this conference?
  2. How will you disseminate information obtained at this conference to local or statewide consumer groups?
  3. What are the specific issues, related to mental health, in which you are most interested?
  4. Are you currently involved with any related programs or activities? If yes, please describe.

Please provide at least one letter of recommendation with your completed application.

Conference Attendance and Travel Conditions

Please note that to be eligible for this opportunity, you must be a U.S. citizen and a person who identifies himself/herself as a person who has a mental illness. If you are selected as a recipient, the Executive Director (upon notification)will contact you by August 15, 2014, to discuss logistical arrangements. Funding will cover the conference registration fee, Hotel expense (based on double occupancy – you will be assigned a roommate who will also be funded by a CAC scholarship), ground transportation, airfare, baggage allowance for ONE BAG (weighing less than 50 pounds), and per diem (daily allowance for meals and incidental expenses not covered by the conference).

As a conference attendee recipient, you will be asked to do (or be aware of) the following.

  1. Submit a 2 to 5 page report to CAC, in a format provided, within 2 weeks of the conclusion of the conference. Your report will be summarized and shared with CAC Board of Directors, KDADS, GBHSPC, and others.
  2. Submit a completed evaluation form within 2 weeks of the conclusion of the conference. The form will be provided.
  3. Submit a completed travel reimbursement form within 2 weeks of the conclusion of the conference (for in-state travel to the airport in Kansas).
  4. Share a hotel room with another person during the conference.
  5. Agree to have your name and contact information shared with CAC, KDADS, and other CAC scholarship sponsored attendees.
  6. Inform the CAC Executive Director, as soon as possible, if you are unable to attend the conference or will be delayed in meeting any of the above conditions.
  7. Be prepared to fly with one connection to Orlando.
  8. We will do a lot of walking!!!!! Be prepared for this!!!
  9. There is a one hour time difference between Kansas and Florida. You fly out of Garden City, Manhattan, Kansas City, or Wichita on October 21, 2014, and return October 26, 2014.

Signature ______Date ______

Please submit your completed application to:

Gary J. Parker

CAC Executive Director

358 N. Main

Wichita, KS 67202

Phone: 316-978-5842 or 785-432-0412

Please note that in order to be considered for this conference, your completed application must be received by CAC viaU.S. Mail, and be postmarked on or before thedeadline of July 10, 2014. NO FAXED, HAND DELIVERED, OR E-MAILED SUBMISSIONS WILL BE ACCEPTED.