Cynthia Wachenheim Memorial Scholarship Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This scholarship is available only to New York providers.

Thank you to the Wachenheim Family and Karen Wachenheim's amazing Zumbathon Fundraisers for this generous and meaningful scholarship fund. May Cynthia's memory be a blessing.

** Scholarships are awarded only before a registration; we don't provide refunds to registrations already purchased. **

Scholarships are given only for PSI trainings, or the PMH-C exam. This scholarship is not available for the annual conference.

Email *

Do you live or provide services in New York? (required) *

yes

Other:

Are you a member of Postpartum Support International? (PSI) (see http://www.postpartum.net/join-us/become-a-member/) *

yes

not sure

Name *

Mailing Address (street or PO Box) *

City, State/Province *

Telephone *

Occupation *

Employer

Are you currently a student, medical resident, or intern?

yes

Other:

Clear selection

Briefly describe your involvement in perinatal mental health: *

How long have you been involved in this field? *

Give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference: *

Would you like to use the scholarship to take the certification exam, or to attend a training?

certification exam

training

Clear selection

If you would like to take a training, what training would you like to attend? Here's a link to the trainings. https://www.postpartum.net/professionals/trainings-events/ *

Virtual - PSI 2-Day PMH Certificate Course

Virtual - PSI Advanced PMH Training

In-Person PSI 2-Day PMH Certificate Course

In- Person PSI Advanced Certificate Course

PSI/Policy Center 8-class Webinar Series

Other:

Required

What is the date of the above training(s) you've selected?

Briefly describe what specific information, skills or contacts you will be seeking at the training, and how you want to make use of them:

Amount of scholarship request (maximum is $400)

$200

$250

$300

$350

$400

any of the above

Clear selection

What financial circumstances require you to seek a scholarship? *

Can you provide bilingual and/or bicultural expertise? *

yes

some

Have you attended a perinatal mental health training before? *

yes

Is there anything else you’d like the Scholarship Committee to know?

Any other questions?

Clear form

Never submit passwords through Google Forms.

This form was created inside of Postpartum Support International. Report Abuse

Forms