Home » Agency Scholarship Form

Agency Scholarship Form

Agency Name
Type of Agency
Your Name
Title
Description of Population Served
Address 1
Address 2
City
State
Zip
Phone
Fax
Email
Please check the activities you are interested in:
CanoeingWhitewater RaftingClimbingSnowshoeingCross Country SkiingOvernight SLC Campouts or Yurt Trips
Is there specific dates you have in mind?
Specific Amount *
How many trips do you anticipate for the year?
Number of Participants on average trip (8 minimum)
Are you able to provide transportation for your group to and from this activity?
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:
Your Name
Date
Print Name as Signature
For Splore Official Use Only: [ ] Eligible [ ] Not Eligible _____% Scholarship Approved/Denied: ___/___/___ Funded by: ____________ Program: _______ Amount: _________