EducationAppendix D

Occupational Therapy Association of HawaiiCONTINUING EDUCATION GRANT - Application Form

Member Name: _______________________________ □ OTR □ COTA

Address: _______________________________ Years in Practice:_______________

City, State, Zip: _________________________________________________________

Phone: (Day) ____________________ (Alternate)__________________________

Title of Course:________________________________________________

Location:_______________________ Date: _________________________

Tuition (Registration Fee): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = $ __________

Airfare: From: ______To:_________; From: _________To:________ =$ ___________

Hotel: # of days:_________@ $ ___________per day . . . . . . . . . . . . .=$ ___________

Car: # of days _________ @ $____________per day . . . . . . . . . . . . =$___________

Other (Describe):______________________________________ =$___________

TOTAL $ __________

Please answer the following questions, attaching your answer sheet to this application. There is no minimum or maximum length to your answers.1. Why should you be selected to receive this grant?2. Why have you chosen this educational event?3. Describe your client/consumer population that you currently serve and the

population that would benefit best from this course. Please provide a number breakdown of the population served in a year (i.e., 100 shoulder injuries, or 50 strokes or 100 ADHD, etc)

4. How long have you served this population in Hawaii?5. After completion of this course, how will the client/consumer in your community best

be served?6. Describe the anticipated outcome(s) of the client/consumer as a result of taking this

course.

Also, please list all activities you have been involved with the Association.

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EducationAppendix D

(By signing this form, you oblige to comply with the eligibility rules set forth in this application instruction and subject to refund the total monetary award amount back to OTAH if you do not fulfill the requirements.)

Signature: ____________________________________ Date: ______________

All applications must have all of the following completed forms enclosed in one envelope and postmarked no later than the June 30th deadline. Any incomplete applications will not be eligible:

1. Application form2. Answer sheet to the 6 questions3. Copy of your current NBCOT certification4. Copy of your current AOTA membership card (if a member)5. List of activities involved with OTAH6. Course information with brochure7. Copies of original receipts (if already attended course)*

*(Remember, IF course attendance is scheduled after the selection has been made, then copies of your original receipts and certificate of attendance must be mailed and received in one envelope within 3 months of course date. Your award will be mailed to you once your receipt and certificate of attendance is received.

Mail to: OTAH Grant Selection Panel c/o 1360 S. Beretania Street, #301 Honolulu, HI 96814.

Deadline: June 30th for grant awarded September 30th** of that year.

** OR as soon as approved by the Board.

You will be notified by mail if selected to receive the award.

Final Board Approved 2-21-13

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