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Scholarship Request Form
Please fill out this form as thoroughly as possible. Teton Adaptive scholarships are generously provided by Bank of Jackson Hole, the Cairn Foundation, and others.
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* Indicates required question
Email
*
Your answer
What is your name (if you are applying on behalf of someone else)?
Your answer
Are you applying on behalf of an individual, family, or a group? Select
Individual
Family
Group
Clear selection
Name of participant
*
Your answer
Email of participant
Your answer
Address
*
Your answer
Phone number
Your answer
What is the name of the activity or program the participant, family, or group will engage in?
*
Your answer
What is the total cost of the program the participant, family, or group will engage in?
*
Your answer
What is the total percentage of scholarship being requested by the participant, family, or group will engage in?
50%
25%
Other:
Clear selection
Who is your current employer? (of the person who takes care of the finances)
Your answer
What is your current job title?
Your answer
How long have you been with your current employer?
Your answer
Are you part of a single parent household?
Yes
No
Maybe
Clear selection
How many people are in the household?
Your answer
How many children are in the household?
Your answer
How many people with disabilities are in the household?
Your answer
What is the percent of household income related to long-term medical expenses?
Your answer
Select any program(s) that the participants, family, or group may currently be receiving assistance from.
AIDD/AAIDD
Aid for Dependent Children
Disability
DSPD
Foster Care
Free School Lunch Program
Medicaid
SNAP/Food Stamps
SSI
Subsidized Living Program/Low-Income Housing
Temporary Assistance for Needy Families
Unemployment Benefits
Women Infants and Children (WIC)
Other:
List any other assistance programs the participant, family, or group may currently be receiving assistance from.
Your answer
How will the requested scholarship help the participant, family, or group?
Your answer
Describe what will be gained by participating in Teton Adaptive programs.
Your answer
Describe any financial burdens or additional factors that Teton Adaptive should consider when assessing this scholarship application.
Your answer
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