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INDIVIDUAL Request - Grant Payment Application
*
1.
Requestor
Information
(Required.)
Your Name:
Your Title or Position:
Request Date:
*
2.
Student/Beneficiary
Information
(Required.)
Name:
School:
Grade:
Description of Need (camp, course, equipment, etc.):
Date of Program/Camp/Course:
3.
Provider/Payee
Information
Provider/Payee Name:
Due Date:
Amount ($):
Provider Contact Name:
Contact Information:
Website (if applicable):
4.
If online payment is possible/necessary, please provide login credentials so we can access the website for direct payment:
User ID:
Password:
*If the request is for a program, lessons, or camp, please answer the following questions
5.
Has financial aid been requested from the provider?
Yes
No
6.
If Yes, how much was approved, if any?
Amount approved, if any:
7.
Has another group or non-profit been asked to cover the cost?
Yes
No
8.
If yes, please share the name of the organization and how much was approved, if any?
Name:
Amount approved, if any:
9.
How much can the family contribute?
