Legal First Name:
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Legal Middle Name:
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Legal Last Name:
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What name do you go by?
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Address:
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City:
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State:
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Postal Code:
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Personal E-mail:
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Home or Cell Phone (xxx-xxx-xxxx):
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Highest educational degree previously received (degree, year):
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Congregation Name (or name of employing institution if you are a chaplain or counselor):
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Congregation/Institution Location (city, state):
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Congregation/Office Phone Number (xxx-xxx-xxxx):
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If yes, please describe. Have you applied through them?
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Event/Program Name:
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Event/Program Date including year:
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Event/Program Location:
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Describe the event for which you are seeking funds: please include information regarding how this is educational:
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Sponsoring Institution:
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Event Contact Person Name:
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Event Contact Person Phone Number (xxx-xxx-xxxx):
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Event Contact person E-Mail:
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If yes, what degree?
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Event/program anticipated date, including year, of completion:
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If yes, please provide name of such organization:
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Please briefly and clearly explain how this experience for which you are requesting funds is an educational endeavor and will benefit your ministry (100 words).
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Date and nature of most recent continuing education event/program?
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If yes, what year(s) was/were grant(s) received? Please list your legal name when grant(s) was/were awarded.
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Total family income (including housing allowance or 15% of base salary if parsonage is provided):
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Number of exemptions reported for income tax purposes:
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Additional information bearing on financial need:
Tuition or registration fees to be paid to sponsoring institution or organization?
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Additional cost for travel, if any:
Additional cost for lodging, if any:
Additional cost for meals, if any:
Total cost of event/program:
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Amount applicant will personally invest:
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Amount congregation or other church-related employer will invest:
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Amount of scholarship sponsoring-institution and/or other organization(s) will invest:
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Amount requested from Disciples Home Missions (cannot be more than $500):
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Total shared cost:
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If you are human, leave this field blank.
