NCIMHA Scholarship Form 
In order to make Endorsement and reflective supervision/consultation (RSC) accessible to infant and early childhood professionals, NCIMHA has set aside a small portion of funds to pay fees (full or partial) for Endorsement applicants. 

NCIMHA developed this rubric to manage those funds, putting an emphasis on offering scholarships for BIPOC providers, bilingual providers,  those who work in under resourced areas of our state and/or with at-risk subsets of the infant and early childhood population. Please complete this form honestly and completely.

Once you complete this form you will be notified about your scholarship eligibility by a NCIMHA representative. If you have questions please contact us at Endorsement@NCIMHA.org
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Email *
Name *

I have spoken to the people in my organization who authorize payment for professional development and training opportunities for me about Endorsement and RSC. My organization is not able to pay the associated fees. 

I would be expected to pay the fees out-of-pocket myself and can not be reimbursed by my employer. 

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I am a child care professional (family home care provider, assistant teacher, teacher, or administrator)
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I identify as a person of color.
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I am fluent in more than one language. I use my language skills in my work with children and families with limited abilities to communicate in English.
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I work in the following county/counties (select all that apply):  *
Required
I provide services to infants, toddlers, young children and families experiencing homelessness.
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I provide services to infants, toddlers, young children and families involved in the child welfare system/child protective services/foster care.

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I provide services to tribal, indigenous, or Native American infants, toddlers, young children and families
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