Agency Financial Aid Application

Please use this form if you are a school, agency, community group or treatment center.

Financial Aid Form: Agency

Agency Name
Type of Agency *Day Camp, In-patient facility, after school program?
Description of Population Served
Your Name
Title
Address 1
City
State
Zip
Phone
Fax
Email *
How did you hear about us? *Word of mouth, social media, print ad, etc.
Please check the activities you are interested in:
Canoeing/SUPIndoor ClimbingOutdoor ClimbingWhitewater RaftingSnowshoeingCross Country SkiingOvernight SLC Campouts or Yurt Trips
Preferred Dates If your dates are flexible, let us know above. We may be able to award more financial aid if you can join us on short notice.
Dollar amount you are requesting in financial aid to cover total trip fees ***We do not offer financial aid greater than 90% of the retail cost** If your trip cost total is $600 please enter the total dollar amount of financial aid you are requesting i.e.: if you are requesting 90% in financial aid and your trip cost is $600 (10 participants x $60ea) you would be requesting a total of $540
Are you able to provide transportation for your group to and from this activity? *
Are you able to make the 10% deposit (based on the retail cost of your trip BEFORE any financial aid is applied) within one week of booking your trip? *
Number of Participants *
Will you obtain aid from other sources (fundraising, grants, sponsorships)? If so, please list the amount.
What goals/outcomes do you want your clients to experience through Splore’s activities?
Please provide any other information that would be helpful in processing this application:
Please list your agency's Account Payable contact information *This information is necessary to finish processing your scholarship application.
Date
Print Name as Signature
For Splore Official Use Only: [ ] Eligible [ ] Not Eligible _____% Scholarship Approved/Denied: ___/___/___ Funded by: ____________ Program: _______ Amount: _________
Email
Email

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Financial Aid Form: Agency

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