PARENT SCHOLARSHIP FORM STRENGTHENING THE CIRCLE INCLUDING INDIAN CHILDREN & YOUNG ADULTS WITH DISABILITIES ANNUAL CONFERENCE APPLICATION DEADLINE DECEMBER 10, 2012 Name: ______________________________________________________________________ Address: _________________________________________ City: _______________________ State: _______________Zip: _____________Email:__________________________________ Phone: ______________________ Best time to reach you at: Day? _________________ Evening? _______________ Child’s age: ________________ Disability_________________________________ Your relationship to the child with disabilities: Parent? Grandparent? Aunt?: ___________________________________________ **In order to assist as many families as possible to attend, we are unable to cover all of your costs (including dinners, taxi & shuttles) to attend this conference.** What are you requesting the funds for? Hotel cost (maximum 3 nights)(please indicate if you want a room for one night or two) o Double room (up to 4 people) $89.00 plus taxes Registration cost -$125.00 If Driving To The Conference: Gas card Child care cost (maximum $75.00) What other agency have you applied to for support to attend this conference? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ How will you share the information you learn at this conference with other families? _____________________________________________________________________________ _____________________________________________________________________________ I wish to support your organization by: Getting the word out about your programs in my area. Become a parent leader to pass information along to families in my region Contact agencies in my area to distribute information about your organizations. FOR OFFICE USE ONLY: Date Rec’d: Approved/Not Approved Amount Granted: Date Applicant Contacted: Applicant: KEEP THIS PAGE FOR YOUR RECORDS! You will be notified by phone and mail about your scholarship. This conference is sponsored by: The National Indian Parent Information Center PO Box 2334 Grants Pass, Oregon 97528 1-855-720-2910 (toll free) www.nipic.org Conference Date: Tuesday, January 29 & Wednesday, January 30, 2013 Location: Sheraton Portland Airport Hotel 8235 Northeast Airport Way Portland, Oregon 97220-7624 (503) 249-7606 DEADLINE FOR ROOMS: DECEMBER 10, 2012 Scholarship check list: I have tried (or received) other funding from the following agencies (please circle): 1. My tribe 2. Developmental Disabilities councils 3. Service clubs or other organizations Worked with others from my area to carpool to save on costs Filled out a scholarship application for expenses. You will be notified about approval of scholarships funds no later than a week after we have received your application. After being notified of approved scholarship, you must fill out a conference registration form online, by fax or email. If you did not request Hotel cost, you will need to make your own reservation!
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