IN-TIME Scholarship Application

Date of Application

PERSONAL AND PROFESSIONAL INFORMATION

Applicant Name

Mailing Street Address

City State Zip

Phone

Current Position/Title

Date you started in current position

Total number of hours you work per week

If your current position is supervisory, what is your current direct care FTE?

Your Supervisor’s Name

EDUCATION

College/University Degree Major

Graduate School Degree

APPLICANT AGREEMENT FORM

In applying for the IN-TIME Scholarship, I hereby agree to the following (please check each individual box):

I grant Connected Beginnings permission to contact my supervisor for references if I am awarded a scholarship.

All of the materials submitted as part of this application are true representations of my academic and employment history.

Signature Date

Please submit the following with your application:

Letter of Reference from your program director or other appropriate agency representative, endorsing your participation and agreeing to support your efforts. For self-employed practitioners, a letter from a professional colleague who is familiar with your practice is required.
Current resume.

to Cathy Abbott either by mail at Connected Beginnings Training Institute, Wheelock College, 200 The Riverway, Boston, MA 02215 or by email at cabbott@connectedbeginnings.org.