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The Loka Institute

Community Research Network 4th Annual Conference

“Re-shaping the Culture of Research: People, Participation, Partnerships &Practical Tools”

University of Texas-Austin * July 6-8, 2001

Scholarship Application Form

(Download "01ConfScholarshipApp.rtf") (Scholarship form page)


(Scholarship applicants do not need to fill out regular registration form)

To be considered as a scholarship recipient, this form must be completed and postmarked no later than May 1st, 2001. All email applications and faxes must be received by May 1st, 2001.

Scholarships are limited. Scholarships will be issued on the basis of your application. You will be notified by May 11th regarding your award.

 Please print clearly:

Full Name:____________________________________________________________________________

Mailing Address: _______________________________________________________________________

City: _______________________________ State:________ Zip:____________ Country:_____________

Day Phone:_____________________________________ Fax:___________________________________

Email:________________________________________________________________________________

How did you hear about this conference?

____Direct Mail    ____Email    ____Loka Website    ____Word of Mouth    ____Other______________

Race/Ethnicity:_________________________________________________________________________

(Your response is optional but we are committed to ensuring a diverse group of participants)

Are you ____Male    ____Female (this information is needed for matching roommates)?

While attending the conference would you be interested in being a Notetaker for one or more of the workshops? We are looking for people who can take clear and comprehensible notes that will later be used for writing the 2001 Conference Report.

 ____ I would like to volunteer as a Notetaker (if you volunteer, we will contact you in advance to discuss details)

For Office Use Only                                                  Date Received:____________________

 Entered in ACT____          Bio Submitted____     Confirmation Sent____     Room Assigned____           

Amt rec’d $_________       Check #_____________        Balance Due $______          

 Registration Packet Complete_________    Balance Paid/Date/Chk #________________________________

____Notetaker        

 

I am applying for (check one):

____ Partial Scholarship (Please choose)

                ____Travel Expenses*

                ____Room and Board (on-campus housing and meals)

                ____ Registration Fee

*Upon acceptance, we will notify recipients of the amount we have allotted for their travel. Scholarship recipients will be responsible for their own travel arrangements. Recipients will receive a reimbursement check for their travel after the conference when they submit their receipts. Special arrangements can be discussed if it is impossible for participants or their organizations to pay for travel up front.

____ Full Scholarship (travel expenses, on-campus housing, meals, and registration)

Special Needs (Dietary, environmental, disability access & needs) please specify:

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

Please use the space below for a brief bio. This information will be used for the conference participation bio list unless you specify otherwise. (Please type or print clearly)

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

We ask that you answer the following questions (print clearly).

1)       Describe your current work and the community with which you work. Include a description of any community-based research projects you are involved with in your community.

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

2)       What will your participation in the conference bring to the community with which you work?

Please describe your plans for sharing what you learned.

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

3) Give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference.

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

4) Explain your need for a scholarship.

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

5) Please include the names and phone numbers of two references that can speak to your work in the community.  

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

                                                                                                                                          

Questions? Call us or email us.

Send this completed form to: The Loka Institute * PO Box 355 * Amherst, MA 01004-0355

 (Phone) 413-559-5860 * (Fax) 413-559-5811 * (Email) Loka@Loka.org * (Website) www.Loka.org


Agenda Video: CRN 2001 2001 CRN Call Registration Scholarships FAQ: CRN 2001

 

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