| Spina Bifida Resource
209 East State Street, Quarryville, PA 17566 717.786.9280 [email protected] Spina Bifida Recreation Scholarship Request Form Date __________________________ Name of applicant ___________________________________________ DOB___________________ Address____________________________________________________________________________ City, State, Zip ______________________________________________________________________ Phone ________________________ Email _______________________________________________ Parents (or guardians) for minors _______________________________________________________ Spouse ____________________________________________________________________________ Type program: ___ Horseback Riding ___ Camp ___ Recreation Program ___ other _____________________ Total Cost ________ Amount Requested ________ Remained funded by _______________________ Name of program _________________________________________ phone _____________________ Address ___________________________________________________________________________ Reason for request ___________________________________________________________________ 50 word on What this program means to you _____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Signature (by parent if for minors) ______________________________________________________ (Any additional information that you feel we need to know can be listed on the back or another paper.) Office use: Approved: ______ reason _____________________________________________________________ Paid to ______________________________________ Check # ________ Date __________________ |
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