Application for SPICE Grant
Thank you for applying for grant funding through SPICE. Please fill out the form below as completely as possible.
Name of Funding Recipient
First Name
Last Name
School Currently Attending
Parent/Guardian Name (First and Last)
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Services Needed:
Estimated Cost:
Have you requested funds from other sources for this service?
Yes
No
Is this service covered in part by insurance? If yes, explain below
*
Yes
No
How many people are in your household? Include yourself, spouse, and any dependents
*
How many people in your household attend a tuition-based school? (Grade school, high school or college)
*
What is your household Adjusted Gross Income for 2021 on IRS for 1040 line 7?
*
Additional Income not reportable? If yes, please explain below.
Name of Provider for services being requested:
Contact information for provider of services be requested:
Please provide the name of the teacher, doctor, or specialist recommending these services:
Any Additional information you would like to provide for consideration
If you have any questions, please contact Diane Wagner at 314-822-1347 x3008 or dwagner@stpeterkirkwood.org
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