First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email *

Phone *

G Number *

1. Describe your commitment to providing behavioral health services to Michigan residents *
Please enter at most 250 words. You currently have:

2. Explain how your background, experiences, or education have prepared you to serve the behavioral health needs of Michigan communities. *
Please enter at most 250 words. You currently have:

3. Outline your long-term professional goals and how they align with behavioral health service needs in Michigan. *
Please enter at most 250 words. You currently have:

Attach a copy of your updated resume in a Microsoft Word Document *
Please upload a file with the extension .doc, or .docx with a maximum size of 1 MB (1024 KB)

Provide a brief statement explaining your financial need for this stipend *
Please enter at most 200 words. You currently have:

List any other sources of funding you are currently applying for or receiving. (e.g. loans, grants, scholarships, fellowships, part-time work) *

By signing below, you certify that the information provided in this application is accurate and complete to the best of your knowledge. You also agree to commit to providing mental health services to Michigan residents for a specified period, as determined by the scholarship terms.

Further you understand that you agree to the following:

• Remain enrolled in the full-time advanced standing MSW program at Grand Valley State University
• Satisfy all requirements for completion of the MSW degree in the full-time advanced standing program.
• Commit to a plan to pursue full-time employment working within the public behavioral health sector in the State of Michigan for at least two years.
• Apply for a Limited Master’s Social Work License upon graduation through the Michigan Department of Licensing and Regulatory Affairs (LARA).
• Complete and submit all required information necessary for accurate reporting and project documentation for MDHHS.
• Consent to completing survey questions during orientation prior to starting the advanced standing MSW program, during the program, and post-program.
• Respond to requests post-graduation for information necessary for program reporting purposes such as licensure status and career placements; and
• Keep Grand Valley State University staff apprised of my professional development.

Please sign below

Please date signature *
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