Application for CDPAANYS Lobby Day Scholarship

Please complete the following questions to apply for a Lobby Day Scholarship. All questions must be answered. For those that do not apply to you, write "N/A."

Your Full Name:

Telephone Number:

Email:

Fiscal Intermediary:

Do you work for a Fiscal Intermediary?
YesNo

Are you a Consumer or Designated Representative?
ConsumerDesignated Representative

How long have you been using CDPA?

Where will you be traveling from?

What is your anticipated mode of transportation?
BusCar/VanTrain

If you will be traveling by bus or train, what is the anticipated travel cost to Albany?
(This is not binding and will not affect your application; it is for planning purposes only)

What issues affecting CDPA are of greatest importance to you and why?

Please describe your history with advocacy and activism related to CDPA:

What previous involvement do you have, if any, with CDPAANYS?

Please list and describe any CDPA-related advocacy events and/or activities you have attended and/or participated in:

Please list and describe any additional activities you believe are relevant to this scholarship application (community groups, committees, boards, etc):

How will you continue your advocacy after Lobby Day?

Leave a Reply