The Center for Reintegration

Back to Work, Back to Life

Step 2: Application Form

Name *
Name
Phone *
Phone
Are You in School Now? *
Most Immediate* desired outcome (check ONE): *
*For example, if you wish to eventually attain a PhD but have not yet completed your undergraduate studies, mark “Bachelor’s degree.”
Are you Currently Employed *
Personal Consent & Release *
Personal Consent & Release
By signing this Personal Consent & Release Form, I confirm that 1. I am participating voluntarily in the Baer Reintegration Scholarship (BRS) (known as the “Program”). I permit Baer’s vendor, the Sidney R. Baer Jr. Foundation and the Center for Reintegration (administrator of the Program referred to as “Program Administrator”), and/or Baer to contact me regarding my status as an applicant of the Program and with regard to any subsequent issues/questions that may arise related to my participation in or status of my application for the Program. 2. I hereby release both Baer and Program Administrator, their agents, employees, licensees and assigns, from and against any and all claims which I have, or may have, for invasion of privacy, defamation, or any other cause of action arising out of any contact related to the Program or arising out of general public understanding that the Program is open to those battling mental illness. 3. In the event that I change my mind about future contact with the Program Administrator or others formally involved with the Program, I will submit a written statement withdrawing from the Program to Baer Reintegration Scholarship Program, PO Box #35218, Philadelphia, PA 19128. Within ten (10) days of receipt of such notice, the Center for Reintegration will take reasonable steps to stop any further contact with me with respect to the Program. 4. I understand that withdrawing from the Program as stated above will immediately disqualify me as a potential recipient of any funding/winning status granted by the Program. 5. I understand that signing this form does NOT ensure that I will receive funding or be chosen as a recipient of the Program, simply that I am agreeing to participate in the Program and to be contacted regarding my participation and/or status in the Program. Should I be chosen as a Baer Reintegration Scholar, I am also agreeing to work with Program Administrator in arranging the scholarship funding for the educational facility that I attend. By typing in my name below this Personal Consent & Release Form, I am agreeing that I have reviewed and approved it and confirm that it is true and correct in all respects. I affirm and attest that I am currently 18 years old or older and understand that in order to accept this offer I must be 18 years old or older.
Date *
Date