IPUL Parent Scholarship Request Form

IPUL Parent Scholarship Request Form

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Idaho Parents Unlimited

Information About You

Are you a:

Parent of a child with a disabilityFamily Member providing primary care

First Name:

Last Name:

Phone Number:

Email Address:

Demographics:

Join Mailing List

If you would like to be on IPUL's mailing list check this box.

Mailing Address

Mailing City

Mailing State

Zip Code

This address is my

HomeWork

Information About Your Child

Please only enter information for an individual child, you will be able to add more children below if needed.

Child's First Name:

Child's Last Name:

Child's Gender:

FemaleMale

Child's Birthdate:

Child's Demographics:

Child's Diagnosis:

Do You Have Another Child to Enter?

YesNo

Information About Your Child (2)

Please only enter information for an individual child, you will be able to add more children below.

Child 2's First Name:

Child 2's Last Name:

Child 2's Gender:

FemaleMale

Child 2's Birthdate:

Child 2's Demographics:

Child 2's Diagnosis:

Do You Have Another Child to Enter?

YesNo

Information About Your Child (3)

Please only enter information for an individual child, you will be able to add more children below.

Child 3's First Name:

Child 3's Last Name:

Child 3's Gender:

FemaleMale

Child 3's Birthdate:

Child 3's Demographics:

Child 3's Diagnosis:

If you have more than three children that you need assistance with, our Parent Education Coordinator will take your information directly.

Event Information

Title of Conference / Workshop / Activity:

Date(s) of Conference / Workshop / Activity:

Location of Conference / Workshop / Activity:

Sponsoring Organization:

Please paste a link to the event page:

We will need a copy of your registration confirmation. Please either attach a screenshot of your registration confirmation below, or in most modern browsers choose print-save as PDF and attach the PDF of your registration. (If you need assistance please contact us.)

Please attach a copy of your event registration

Expenses

Please enter the dollar amounts here as a whole number, without a dollar sign. For instance $20.00 would be 20

Transportation Cost:

Estimated Meals / Hotel Cost Totals:

Registration:

Parking:

Taxi:

Respite:

Other:

Total Amount Requested:

Acknowledgement:

I understand that there is a $600 maximum available per family per year.

Have you recieved a scholarship from IPUL in the past?

YesNo

Date Received:

Amount:

What do you hope to learn from this Conference / Workshop / Activity?

How will you share or use the information with parents and/or persons in your community, school, district, and/or state?

What do you personally hope to gain from attending this Conference/Workshop/Activity?

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Contact Information