Foundations in Gaming Disorder Scholarship - Evergreen Council on Problem Gambling

Scholarship Application Form

Treatment providers not eligible for problem gambling counselor certification may still be eligible for scholarships depending on funding available.

Deadline for scholarship applications is 10 days prior to the start of the event. Scholarships include: Registration for up to four days, Washington State Gambling Counselor Certification application fees (for those who have not yet applied), and ECPG membership for those not currently members.

All scholarship recipients who accept a Professional Development Scholarship from Evergreen Council on Problem Gambling must make a commitment to attend all sessions on all days for which a scholarship is awarded. If a scholarship recipient is not able to attend all sessions on all days for which a scholarship is awarded, ECPG must receive advance notification and the scholarship may be retracted if deemed appropriate. If advance notification is not offered, the scholarship recipient may risk eligibility for any future scholarship awards.

Completed scholarship application form and supporting documentation - with a completed training registration form - must be submitted by the application deadline. Applications received after the deadline will be considered only if funding is available.

Applicant Type*
Applicant Name*
Credentials
Date of Birth*
MM slash DD slash YYYY
Age (must be 18 years or older)*
School Name*
School Address:*
Position/Title
Agency/Organization
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Phone*
Cell/Alternate Phone
Email*
Training/Event for which you are applying for a scholarship:*
Use the drop down menu to select the training/event for which you are applying for a scholarship.
Subject(s) Currently Taught:*
Applicant Statement*
Please briefly explain your interest in attending the conference/training workshops, how the training relates to your work, and how you will use and share the knowledge acquired.
Consent*
I attest to the accuracy of the above information. I also agree to write a summary of no less than 500 words of my experience at the training workshops (within 30 days of training) for possible publication in the ECPG websites and Insights newsletter, and participate in all designated programs as assigned at the conference.
I attest to the accuracy of the above information.
Consent*
I attest to the accuracy of the above information.
File Upload*
Upload (1) Completed Training Registration Form; (2) Copy of your current certificate or license issued by the State of Washington to provide mental health or chemical dependency treatment services to the public.
Drop files here or

Accepted file types: pdf, doc, docx, png, Max. file size: 300 MB.
File Upload*
Upload (1) Completed Training Registration Form; (2) Proof of successful completion of a Recovery Coach Academy Training with a copy of the signed and dated Certificate or a signed and dated Certificate from another SAMHSA-approved Peer Recovery Coach program.
Drop files here or

Accepted file types: png, pdf, doc, docx, Max. file size: 300 MB.
File Upload*
Upload (1) Completed Training Registration Form; (2) Proof of student status; (3) Teacher/Professor Recommendation Form (included in the scholarship application which may be downloaded from the ECPG website under the training tab, Scholarships)
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 300 MB.
File Upload*
Upload (1) Completed Training Registration Form; (2) documentation of current status as either Certified Prevention Professional (CPP) or Associate Prevention Professional (APP).
Drop files here or

Accepted file types: pdf, png, Max. file size: 300 MB.
File Upload*
Upload Completed Conference/Training Registration Form
Drop files here or

Accepted file types: pdf, png, Max. file size: 300 MB.