"I would like to be housed in MSU s Owen Graduate Hall"
2011 MVAA Application Form June 5-10, 2011 I would like to be considered as a participant in the 2011 Victim Assistance Academy. I understand there are a limited number of seats available, and the information provided below will be used to identify candidates with at least one year’s experience in working with victims of crime and who show a long term commitment to the victim services field. Teams of victim service providers from various disciplines within a local area are encouraged. Selection will also be influenced by our desire to reflect diversity (geographic, racial, ethnic, etc.) in participation. Please print or type legibly. Date: _________________________ Full Name (as you would like it to appear on certificate): ____________________________________________ A. Work/Employment Information: Current title/position: __________________________________ Email: ________________________ Organization/Employer: ______________________________________________________________ Address: ___________________________________________ County: _______________________ City: _________________, MI Zip: _________Phone: ________________ Fax: ________________ Last 4 Digits of your SS#: ____________________ MCOLES Number: _______________________ B. Home Contact Information: Phone: ____________________ Fax: __________________Email: ___________________________ C. Accommodations and Academic Credit Information: ___ YES, I would like to be housed in MSU’s Owen Graduate Hall. I understand I will have a single room, but will share a bathroom with a suitemate. ___ Male ____ Female ____ Handicapper Needs ____ Dietary Restrictions ____ If accepted to the Academy, I will make separate lodging arrangements at my own expense. ____ I am a currently enrolled ___ graduate ___ undergraduate student at Michigan State University (or give institution of higher education where enrolled _______________________________) and will be enrolling for academic credit as part of my program of studies. (MSU credits = 3) ____ I am not a currently enrolled graduate/undergraduate student at MSU. I understand I will receive MSU Lifelong Continuing Education credits. (The Academy is MCOLES certified and has been approved for 4.5 CEU credits.) D. Team Application Information: If you have applied to the Academy as part of a team, please provide the names of all team members: __________________________________ ___________________________________________ __________________________________ ___________________________________________ E. Background Information: 1. I have ____ years experience working with victims of crime. Please provide the following information about that experience (Attach an extra sheet if more space is needed): Agency Primary Type of Service Jurisdiction Primary Type of Years of Experience (Court, Police, Provided (Federal, State, Victim Serviced (Please provide dates – Prosecution, Juvenile (Advocacy, Shelter, County or Local) (DV, elderly, child i.e. 1990-1994) Justice, etc.) Counseling, etc.) abuse, sexual assault, etc.) 2. Please attach a resume that details your educational background, position/titles, responsibilities and dates of service. 3. Please attach a summary that addresses each of the following points: a. Briefly state what are your long-term personal goals and how completion of the Michigan Victim Assistance Academy fits into (enhances) those goals? b. Briefly state what are your long-term career/professional goals and how completion of the Michigan Victim Assistance Academy fits into (enhances) those goals? c. How will your participation in the week-long Victim Assistance Academy benefit your organization and your community? d. How did you learn about the Michigan Victim Assistance Academy? e. Any additional information you think is important for the selection committee to consider. F. Statement of Commitment: By signing below, please signify your commitment to attend the full 45-hour course and make all travel arrangements accordingly. Name:________________________________________________Date:____________________________ There is no fee to attend the Michigan Victim Assistance Academy. Please mail a copy of your completed application form, with a signed commitment Michigan Victim Assistance Academy Michigan State University - School of Criminal Justice 421 Baker Hall East Lansing, Michigan 48824 (517) 355-9648 or 1-800-892-9051 Fax: (517) 432-1787 www.cj.msu.edu/~outreach/mvaa Your application package must be received no later than May 2, 2011. Handicapper accommodations may be requested by calling the MVAA at (517) 355-9648 thirty days prior to the Academy to ensure sufficient time to make arrangements. Requests received after this date will be met when possible.