parent sc form 2013 by SL4CK0G

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									                            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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