Cynthia Wachenheim Memorial Scholarship Application
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.
Do you live or provide services in New York? (required) *
Are you a member of Postpartum Support International? (PSI) (see http://www.postpartum.net/join-us/become-a-member/) *
Name *
Your answer
Mailing Address (street or PO Box) *
Your answer
City, State or Province, ZIP *
Your answer
Telephone *
Your answer
Email *
Your answer
Occupation *
Your answer
Employer
Your answer
Are you currently a student, medical resident, or intern?
Briefly describe your involvement in perinatal mental health: *
Your answer
How long have you been involved in this field? *
Your answer
Give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference: *
Your answer
What training would you like to attend? *
Your answer
What is the date of the above training? *
Your answer
Briefly describe what specific information, skills or contacts you will be seeking at the training, and how you want to make use of them: *
Your answer
Amount of scholarship request (maximum is $400)
What financial circumstances require you to seek a scholarship to attend the training? *
Your answer
Can you provide bilingual and/or bicultural expertise? *
Have you attended a perinatal mental health training before? *
Is there anything else you’d like the Scholarship Committee to know?
Your answer
Any other questions?
Your answer
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