Women’s Wilderness has a strong commitment to providing financial aid to girls who would otherwise be unable to afford the opportunity of a one of our adventures. However, the amount of financial aid we can award is limited by the amount of funding we receive each year. We ask that you fill out this form with integrity, and make an honest assessment of the fee you and/or your family can afford for your course, so that we can stretch our scholarship dollars to serve as many participants as possible.

Scholarships are provided directly through the generosity of individuals, corporations, and foundations within our community. Those who receive financial aid may be asked to write a thank you letter after the course to the individual or organization that provided their scholarship.

Participant’s Name: / Course Name and Dates:
Address:
Phone:
Email:

1.  Household members

Number of parents
Number of children under 18
Other

2.  Household income (List all jobs held)

Please PRINT clearly

Name / Occupation / Employer / Monthly Income
(Before Deductions)

3.  ALL other household income (welfare, social security, child support, etc.)

Type of Income / Monthly Income

PO Box 20543, Boulder, CO 80308

(p)303.938.9191 (f)303.938.5071

www.womenswilderness.org

4.  Total Monthly Household Income
(question 2+3)

5.  Are there any unusual expenses or circumstances your family is currently facing?

What is the monthly total of these expenses?

6.  Please estimate the maximum amount you believe you can afford for the course.

Participant
Family
Total:

7.  If a payment plan would help you meet this expense, please suggest a schedule.

I certify that the above information is true and complete, and is an accurate representation of all income and funds available to pay for the course.

Applicant Signature (if participant is over 21) / Date
Parent/Guardian Signature (if participant is under 21) / Date

PO Box 20543, Boulder, CO 80308

(p)303.938.9191 (f)303.938.5071

www.womenswilderness.org