The person requesting a scholarship for program fees should complete the following:
Name: ___________________________________________________________________

Agency/School/Organization: _____________________________________________________

Address: __________________________________________________________________

Telephone Number: _________________________________________________

Desired Program Date/Type of Program Desired:

 ____________________________________

Grade Level: _____

Number of Students for which you are requesting a scholarship: ______

Briefly indicate the reasons why you would like to receive a scholarship to cover the expenses of a field trip or program at the Dorothy Pecaut Nature Center. You may use the back of this sheet if necessary.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Demographic Information

Optional;  Complete the following by indicating the number of students who are in each of the following demographic groups:

_____ Asian _____ Native American _____ Female

_____ White _____ Black _____ Male

_____ Hispanic _____ Other _____ Person with mental or physical disability
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For Office Use Only
_____ Approved Date: ____________ Approved By: ___________________________
Please return at least two weeks prior to program date in order to assure scholarship availability.
Return to: Dorothy Pecaut Nature Center, 4500 Sioux River Road, Sioux City, IA 51109