ADED Memorial Scholarship

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	ADED Memorial Scholarship Application Form
The Memorial Scholarship Fund is supported by donations and provides financial assistance for the purpose of attending courses developed and provided by ADED. Up to five (5) $500 scholarships per course will be awarded to eligible applicants.

To be considered for this prestigious scholarship please fill out the application below.

First Name *
Last Name *
Email Address *
Address Line 1
Address Line 2
City *
Location *State / Providence
Zip/Postal Code *
Country *
Phone Area Code *
Phone *
Which course are you planning on attending (choose one) *	Intro to Driver Rehab Mar. 5-6, 2019 Disab., Vision, Aging on Driving Aug 9-10, 2019 Traffic Safety Aug. 9-10, 2019 Intro to Driver Rehab Oct. 18-19, 2019
Are you a current ADED member? *	Yes No	Please list prior years of membership or enter ‘NONE’ *	None 2018 2017 2016 2015
Are you a Certified Driver Rehab Specialist (CDRS)? *	Yes No	Does your present or future employment depend on maintaining your CDRS? *	Yes No
If you are NOT a CDRS, do you plan to take the exam within the next 12 months? *	Yes No I am already a CDRS	How many other driver rehabilitation professionals are at your facility? *
Have you previously received an ADED managed scholarship? *	Yes No	List prior scholarships or enter 'NONE' *
What type of support will your employer provide for attending this course / conference? *	Paid time off Registration fee Travel None	How much can you contribute to your course attendance expenses? *
Hours per week you are involved with driver rehabilitation program services: *		Services provided (check all that apply) *	Evaluation Training Screening None
Indicate number of other driving programs services in your general service area: *
List contributions you have made in the driver rehabilitation profession or to ADED: *
What are your reasons for requesting funding assistance? *
Any additional information you wish the committee to consider:

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