Scholarship Request

Scholarship Request

First Name

Last Name

Phone Number

Email Address

Gender Identity Man Woman Non-Binary Person Other Prefer not to answer

What best describes your reason for requesting financial support? Student Limited/low income Retired Disability/Health-Related Other Prefer not to answer

What is your age group? 18-24 25-34 35-44 45-54 65-74 75-84 85 and above Prefer not to answer

What is the name of the program/retreat you are requesting a scholarship for?

Date the Program Begins (Required format: xx/xx/xxxx)

What is the program/retreat cost?

How much financial assistance are you requesting? (percentage of program/retreat cost) 25% 50% 75% 100%

Please briefly describe what you hope to gain from attending this program/retreat.

Would you be willing to share about your experience at The Well on social media or other outlets? Yes No Not Sure

Have you received a scholarship from The Well in the last 12 months? Yes No

Are you new to The Well? Yes No