SUNY & CUNY Community & Technical Colleges Addiction Professionals Scholarship Program Application

The Addiction Professionals Scholarship Program is funded by the Opioid Settlement Fund.
The scholarship program is an OASAS initiative.

Applicant Information:

First Name

Middle Name

Last Name

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

*Applicants must reside in New York State.

Phone Number

Email Address

Demographic Categories: Please note that all demographic questions (1-6) are optional. Your response(s) or lack of responses will not affect your admission into the Addiction Professionals Scholarship Program in any way. Please select or indicate the appropriate fields below.

1. Legal Sex

Female

Male

X or someone else

Prefer not to answer

Gender Identity: Uses a different term:

3. Gender Identity: Do you identify a transgender?

Yes

No

Questioning/Unsure

Prefer not to answer

Race: Prefer to self-describe

5. Are you Hispanic/Latino?

Yes

No

Prefer not to answer

Hispanic/Latino background: Prefer to self-describe

6. Are you of Asian origin?

Yes

No

Prefer not to answer

Asian background: Prefer to self-describe

7. Are you of Pacific Islander origin?

Yes

No

Prefer not to answer

Pacific Islander background: Prefer to self-describe

Other

9. Do you have the proficiency/fluency to conduct services in other languages?

Yes

No

Other

10. Please select your highest level of education.

11. Has any disciplinary action ever been taken against you as the holder of any license or certification issued by New York State or any other State or Federal agency?

Yes

No

8. a) You answered “yes”, please explain below.

12. Are you listed on the Staff Exclusion List* as an individual who is legally prohibited from providing care and services to a vulnerable person? *defined in Article 11 of the New York State Social Services Law

Yes

No

12. a) You answered “yes”, please explain below.

13. Please check one of the following:
I am an employee of one of the following program types** (Employment Verification Form to be provided upon submission of this form):

Office of Addiction Services and Supports (OASAS) certified/authorized program

Office of Mental Health (OMH) or Department of Health (DOH) certified Integrated Outpatient Services (IOS-SUD) Program

DOH Drug User Health/Harm Reduction Program

Non-certified setting which involves either: 1) the legal provision of addiction services or 2) the opportunity to establish proficiency in one or more of the professional competencies associated with a credential administered by OASAS (that provides addiction care prevention, treatment, recovery or harm reduction services in another setting)**.

I am not currently working in one of the above settings.

14. I am interested in working in one of the OASAS/OMH/DOH settings reflected below (please check all that apply):

Interested in the Office of Addiction Services and Supports (OASAS)

Interested in the Office of Mental Health (OMH)

Interested in the Department of Health (DOH)

15. Have you taken the CASAC program at another Education and Training Provider (ETP) prior to applying to our institution?

Yes

No

15. a) You answered “yes” to the previous question, please provide the following: 1) the name of the ETP; 2) a brief description of the course and content that you successfully completed including the sections, modules, and hours completed; and 3) the sectional certificate that you received from the ETP from which you are transferring.

16. Did you receive a scholarship from OASAS to attend the CASAC program from the ETP from which you are transferring?

Yes

No

16. a) You answered “yes” to the previous question, please list the name of the scholarship and the year that you received it.

17. Please provide a brief statement about why you are applying for a scholarship opportunity for your associate degree and CASAC program, which should include, at a minimum:
• any previous volunteer or work experience along the addictions continuum of care;
• your interest in working in the OASAS Provider System; and
• the qualities you possess that you believe would make you an effective CASAC.

Required Scholarship Application Documents Checklist (you will receive this list via email upon submission of this form):

Addiction Professionals Scholarship Program Application Form
Employment Verification Form (for applicants who selected one of the** employment options above) - this form will be provided via email upon submission of this form.
Three (3) Reference Forms/Letters of Recommendation on affiliate letterhead clearly indicating the signatory’s credentials/title/qualifications to write on the applicant’s behalf (Employment Verification Form may be submitted in lieu of one (1) Reference Form/Letter of Recommendation and is REQUIRED for any applicants who are working in an OASAS/OMH/DOH-certified setting and/or within a setting along the addictions continuum of care at the time of application**)
One (1) professional or academic reference and two (2) personal references (for individuals not currently employed in the addictions field and are unable to obtain three (3) professional references***). A professional reference or academic reference may include a professor, a supervisor, a teacher, or a GED instructor. Personal references are people you know from settings outside of work, including community organizations and social groups. They may include: mentors, people you know from networking or professional membership groups, leaders of social groups and community organizations, coaches or instructors from extracurricular activities, faith leaders and someone who has worked with you on a project or assignment. Note that personal references do not include family members, your spouse, or personal friends. Your personal references should be able to speak objectively about your character and/or about your job-related skills.
Review summary from OASAS (for individuals who received a transcript review from OASAS to obtain transfer credits).
Sectional Certificate (for individuals who took classes at a previous ETP and want to receive transfer credits).
Personal Statement (for individuals not currently employed in the addictions field***).

Please initial this section ONLY if you agree to having your name and program selection shared with the NYS Office of Addiction Services and Supports (OASAS) for inclusion in their data collection regarding the Addiction Professionals Scholarship Program. This is completely voluntary and will NOT, in any way, affect your potential eligibility for a scholarship opportunity. Information will only be shared if you are selected to receive, and agree to accept, an OASAS-funded scholarship award.

Statement of Accuracy/Affirmation

I affirm that all the information I have provided in this application is my work and that it is accurate to the best of my knowledge and belief.

I affirm that I am not currently receiving another scholarship from the New York State Office of Addiction Services and Supports.

Electronic Signature (please type full legal name)