State of Oregon Sponsorship InformationRegion 10 Opioid SummitAugust 7th and 8th, 2019

Vancouver Hilton Conference Center301 W. 6th St., Vancouver, WA 98660

Vancouver, WA

The Oregon Health Authority (OHA), Health Systems Division (HSD), Addiction, Treatment, Recovery and Prevention Unit (ATRP) will be supporting attendance at this conference by offering sponsorship and travel assistance. Sponsorship will cover registration fees for the conference, as well as travel, meals, lodging and conference registration for those selected to receive a sponsorship. We encourage all who are interested to apply. Applications are due to Megan Anaya no later than July 1st, 2019.

Application Criteria

Due to limited resources available, the following criteria will be considered in terms of prioritizing sponsorship applications:

o Geographical location – we encourage applications from across the state, in order to include a diverse cross section of our state’s behavioral health workforce and other interested stakeholders and partners

o Demonstrated financial need; while we want to encourage all Oregonians interested to attend, we want to make sure our resources are maximized in this process by affording spaces to attend to those who would who would otherwise not be able to attend due to financial burden or hardship

o Persons of color or those working in behavioral health settings serving Oregon’s minority and underserved communities

o Peers, those with lived experience, and those working directly within the peer recovery and support network in Oregon

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o Tribal members, those directly working with tribal members and tribal communities, and those working directly in SUD or other behavioral health roles with Oregon’s 9 Federally recognized tribes or Oregon’s Urban Indian program

o Members of organizations working to expand their capacity to deliver medication assisted treatment (MAT) services in their communities

Applicants receiving a sponsorship are encouraged to share information gained while attending the summit with co-workers, other community members and stakeholders; please identify briefly, in a few sentences in the application form below, your plan to do so

All applications must be completed in full or the sponsorship materials will be returned.

Sponsorship recipients are expected to attend the summit activities each day and participate fully in the summit by attending the keynote presentations and workshops, if you are unable to attend during both days of the summit, you will not be eligible for the sponsorship or future sponsorship opportunities supported by OHA.

Submit applications to Megan Anaya via email at megan.anaya@state.or.us no later than July 1st, 2019. You will be notified via email no later than July 8th, 2019 regarding your sponsorship status. Please make sure all forms are completed and signed – incomplete forms or those missing signatures or other key information will not be considered. Please notify Ms. Anaya immediately if after submission of your application you are unable to attend, or within one week of notification of receipt of a sponsorship if you are unable to attend.

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State of Oregon Sponsorship ApplicationRegion 10 Opioid Summit

All information must be completed and submitted to megan.anaya@state.or.us by:

5 P.M Pacific Daylight Time Monday, July 1, 2019

Please note all documents must be signed and complete or your application cannot be accepted.

First Name: Click or tap here to enter text.

Last Name: Click or tap here to enter text.

Name as appears on the name tag: Click or tap here to enter text.

Applicant’s Address: Click or tap here to enter text.City: Click or tap here to enter text.State: Click or tap here to enter text. Zip: Click or tap here to enter text.

Phone Number: Click or tap here to enter text.

E-mail Address: Click or tap here to enter text.

Employer: Click or tap here to enter text.

Employer’s Address: Click or tap here to enter text.City: Click or tap here to enter text. State: Click or tap here to enter text. Zip: Click or tap here to enter text.

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Phone Number: Click or tap here to enter text.

E-mail Address: Click or tap here to enter text.

Would you like to receive future emails about conferences?Yes No

Dietary Restrictions: Vegetarian Vegan Dairy Free Gluten Free Nut Free NA

Note: there may not be an alternative for every item served but dietary restrictions will be considered in meal planning. If your diet is severely restrictive you may want to consider bringing some of your own food as the conference committee cannot be responsible to ensure your dietary needs are met.

Accommodations (Please specify only ADA needs (sign language interpreter, wheelchair access, etc.) Click or tap here to enter text.

I agree to allow sponsors and affiliates of this Summit to contact me regarding news and announcements at my email address provided.

Yes No

Please Check Requested Resources:Lodging Food reimbursement Air transportation Ground transportation reimbursement Registration Stipend

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PLEASE NOTE THAT IF YOU ARE ABLE TO COVER PARTIAL COSTS OF YOUR ATTENDANCE PLEASE DO NOT REQUEST RESOURCES THAT COULD OTHERWISE BE USED BY THOSE UNABLE TO DO SO

In requesting lodging, please be aware that cancelation is required to avoid the expense of that room. Each individual requesting lodging is expected to utilize that room for the nights requested or provide timely cancelation.

I would like to receive Continuing Education Units (CEUs.) Yes No

In the space below, please provide a brief summary of why you would like to attend the Region 10 summit on a sponsorship, including plans for distributing information received, and any other information you would like us to know about yourself, including a focus on the priority criteria listed in the application above:

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Please sign that you have read and understand your responsibility as a sponsorship awardee:

Signature: __________________________________________________________________

Date: _____________________________________

If you have questions about the application, please contact Megan Anaya, Administrative Assistant, at megan.anaya@state.or.us.

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