Name *

First Name

Last Name

As a condition of receiving the scholarhsip, recipients will be required to provide follow-up activities that benefit the EI workforce and/or EI families in Pennsylvania. Which of the following can you commit to providing? *

Select all that apply

Presenting information/resources obtained at a regional EIPA meeting, as well as one additional learning session of your choosing. (LICC, Provider Meeting, County Training Opportunity, etc.)

Initiation of a new project in which you will be engaged or expansion of an existing project in which you are currently engaged, as a result of attending the conference.

Will you be attending the conference if not awarded EIPA funding? *

yes

no

maybe

Have you attended a conference in the past via funding from EIPA (IMH, SEL, Inclusion etc.)? *

yes

no

Is your agency willing to cover costs in excess of the registration fee? *

yes

no