Merlin W. Schultz Professional Development Grant Application
Email address *
Applicant Information
Applicant Last Name *
Applicant First Name *
Specify applicant's status as one of the following: *
Applicant Address (#, Street, City, Zip) *
Applicant Primary Phone Number *
List of professional counseling/mental health organization(s) of which you are a member. *
Applicant License Name and Number *
Geographic Location of your Project *
Purpose and Outcomes of Your Professional Development
IN ORDER TO MAINTAIN ANONYMITY PLEASE USE I/WE INSTEAD OF ANY IDENTIFYING INFORMATION
Provide the Name of the Activity, Training or Conference *
Location of the Activity *
* the Foundation expects that travel will be to the closes quality training/workshop/conference available.
Dates of the Activity *
Itemization of estimated costs *
(Travel, Lodging, Registration, etc.)
How will your participation benefit the counseling/mental health profession in Illinois? *
* Preference will be given to recipients who can demonstrate how their professional development will impact counseling/mental health professionals in Illinois versus Internationally.
How many individuals will benefit from your participation, and in what ways? *
How do you plan to share what you learn? *
Foundation Mission
Mission: In order to promote excellence in counseling and support mental wellness in Illinois, the Schultz Foundation for Advancing Counseling provides financial support that encourages professional development and research and which addresses social issues within the state.
How will your work increase the visibility of the Foundation? *
GRANT CERTIFICATION STATEMENT
By submitting this application, you are requesting funding from the Schultz Foundation for Advancing Counseling, also known as the Illinois Counseling Association Foundation. A funding award comes with responsibilities and obligations. In order to be certain that applicants are committed to following through on their application, the Foundation Board requires the following certifications to be part of the application process. When you sign this application, you will be certifying to the following statements:

1. I/we understand that the selection of award winners is under the sole authority of the Board of Directors of the Schultz Foundation for Advancing Counseling. I agree that if selected I am expected to attend an award presentation at a mutually determined time and location.

2. I agree to use Schultz Foundation for Advancing Counseling grant funds in a manner that values diversity and the worth of every individual.

3. I agree to not discriminate against individuals in the use of Schultz Foundation for Advancing Counseling funds based upon: sex, race, color, sexual orientation, gender identity, gender expression, religion, age, marital status, national origin, disability, veteran status and any other class protected by state or federal laws, except where the nature of the Merlin W. Schultz Professional Development Grant awarded research project requires a focus on a particular group without any hint of discrimination.

4. I/we understand that a blind review is conducted on all applications.

5. I/we agree to perform and complete the counseling project/activity program outlined in the application.

6. I/we agree to be photographed by an agent or agents of the Schultz Foundation for Advancing Counseling and will allow the Foundation to utilize the subsequent photos for promotional and other purposes in keeping with the Mission of the Foundation.

7. I/we agree to reimburse the Schultz Foundation for Advancing Counseling for any grant funds not expended in completion of the project, and to provide a complete accounting of those funds that are spent. Any reimbursement to the Foundation will be provided within 30 days of the scheduled conclusion date of the project.

8. I/we agree to provide a written final report of the project within 30 days of the completion date noted on the application. I understand if awarded a I am / We are required to provide written reports as outlined in application.

9. I/ We agree to make a written request to the Schultz Foundation for Advancing Counseling Board of Directors if I need to either modify or change my approved application. If this is not done and approved by the Board, I agree to immediately refund the grant monies awarded.

10. I agree to maintain and keep the Schultz Foundation for Advancing Counseling informed of my current phone, mailing address, and e-mail address through the duration of my grant activities, and to respond to messages from the Foundation in a timely manner.

11. I/we will conduct my project/program activities in a manner consistent with the Code of Ethics of my profession


12. I/We agree to cite the Schultz Foundation for Advancing Counseling in all workshops and correspondence emanating from or pertinent to the approved project. I agree to work with the Foundation Executive Director to review wording of mention of the grant.

13. I/we have read and agree to the Schultz Foundation for Advancing Counseling Grant Certification Statement.
Signatures
Project Leader: *
If you agree to all of the above items, provide your digital signature in the form of your first, last and middle initial to complete your application.
Supervisor: *
If you agree to all of the above items, provide your digital signature in the form of your first, last and middle initial to complete your application.
Submission
Upon clicking the submission button, your application will be automatically submitted to:

Jenica Hopkins, Executive Director
schultzfoundationgrants@gmail.com
309.306.1193
A copy of your responses will be emailed to the address you provided.
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