Prevent Suicide Greater Milwaukee (PSGM)

QPR Training of Trainers 1/10/2018 Scholarship Application

Scholarship Information:

Scholarships are grant-funded through the generous support of the Charles E. Kubly Foundation.

Grant priorities include giving preference to scholarship recipients who:

Agree to conduct a minimum of three QPR trainings on behalf of Prevent Suicide Greater Milwaukee (PSGM) per year on an ongoing basis.
Agree to participate in PSGM’s QPR mentoring program:a) use PSGM QPR Working Group approved materials on the PSGM QPR google drive, including slides, handouts and evaluations, b) return completed training evaluations to the PSGM QPR Director, and

c) participate in a minimum of 3 PSGM-sponsored QPR trainings in 2018.

Will conduct QPR trainings for Milwaukee community members and organizations who represent the following groups at higher risk for suicide:

a) Men in their Middle Years b) Veterans c) identify as LGBTQ.

Identify as men.
Identify as veterans.
Identify as persons with Spanish language skills, and are able to conduct trainings in Spanish.

Instructions for Application:

Application for the PSGM QPR Training of Trainers Scholarship to cover the $395 training fee includes 2 parts.

Part I: Please complete this form and the Scholarship Agreement Form which follows, sign and date (original signatures only), scan, and email as an attachment to by 12 noon on December 15, 2017.

Part II: (ForApplicants with favorable initial application review)

Participate in a 20 minute phone interview with a member of the PSGM Steering Committee December 18-December 21, 2017.

Notification: Scholarships will be awarded and recipients notified by December 22, 2017.

Application Form

Please complete the follow information (preferably on a computer, or print in black ink):

Name (First, Last):

E-mail address:

Phone (best number):

Mailing Address:

Gender:

Employer: (when applicable)

Organizational Affiliation(s):

Please answer the following QUESTIONS (2 pages maximum)

Have you attended a QPR suicide prevention training? If yes, where and when?
Why are you interested in becoming a QPR trainer?
Which grant priorities (see page 1) will you be able to fulfill?
What is your background in suicide prevention? (Personal/professional) Please describe:
What audience(s) do you plan to train in QPR? (community, work place, other)
Do you have public speaking experience? Please describe:
Please describe your circumstances to support the need for a scholarship.

Prevent Suicide Greater Milwaukee

QPR Training of Trainers 2018 Scholarship Agreement Form

Please complete this form, print, sign/date, and scan/email to

(or mail to Leah Rolando, MHA Wisconsin, 600 W. Virginia, Suite 502, Milwaukee, WI, 53204)

NAME:

PHONE:

EMAIL:

Requirements for scholarship recipients:

Lead a minimum of three QPR Gatekeeper Trainings (90 minutes each) within the first year of training on behalf of Prevent Suicide Greater Milwaukee (PSGM).

You will have opportunities to observe trainings, and be partnered with experienced trainers to conduct your first trainings.
You will have access to PSGM QPR booklets, files and forms to support your trainings.

Notify PSGM of your scheduled trainings.
Return your QPR training sign in sheets and evaluation forms (provided by PSGM) after each QPR training to the PSGM Director of QPR.
Attend supplemental mentoring/update sessions with the PSGM QPR Working Group.
Inform PSGM if your contact email information changes.

PLEASE NOTE: If you do not lead 3 QPR trainings as noted above within one year of your QPR trainer’s certification, you will be required to repay your scholarship funding of $395.00 to Prevent Suicide Greater Milwaukee.

I have read and understand the conditions for receiving a scholarship and will adhere to the conditions stated.

I understand that if I do not lead a minimum of three QPR trainings in 2018 on behalf of PSGM, I will need to repay PSGM $395.00 for my QPR training tuition.

______

Original Signature (NOT electronic) Date

R11/2017