Experiential Learning Grant Application (for Faculty)
As you may know, President Worthen has provided need-based funding for students to help them achieve their academic and career goals involving internships, student teaching, study abroad, and mentored learning (e.g., paying for research assistants on any faculty project). These funds are for psychology majors who would not otherwise be able to have these academic experiences without financial support. If you work with students and are interested in applying for these need-based funds to give students an experiential-learning experience including research mentoring, please complete this form.

Faculty are often more aware of beneficial opportunities or experiences, including possible mentored research, than are the students. In these situations, the faculty member may be more suited to provide the details needed by the grant committee to assess the value of the experience for the student.

Please complete one form per student.

If you have any questions, please contact Dr. Tice by email at dianne_tice@byu.edu.

We do not have a deadline for requesting experiential learning funds as this will be ongoing until we have distributed the funds for the year. Please submit this form below AND email dianne_tice@byu.edu to let her know that you have submitted an application for review.

Faculty Mentor completing this form: *
Your answer
Potential Student Recipient
Student's Full Name *
Your answer
Student's Net ID *
Your answer
Student's Year in School *
Student's Major *
Student's Minor *
Your answer
Student's Expected Graduation Year *
Student's Expected Graduation Month *
Has this student already received experiential learning money? *
Experiential Learning Experience Information
What type of Experiential Learning is this? *
What is the title of this Experiential Learning Experience? REMEMBER: This is not a form for Academic Conferences. For that you need to submit an "Academic Conference Student Travel Grant Application" form. *
Your answer
Semester that this student will participate in this experiential learning opportunity. *
Year that this student will participate in this experiential learning.
How would this specific desired experience help this student achieve his/her academic and career goals? *
Your answer
Financial Needs of Student
If known, and without asking the student, please describe this student's financial needs and his/her inability to have an experiential learning experience without financial support.
Your answer
For Mentored Research (if applicable)
Enter the number of WEEKS you would expect the student to work with you doing research.
Your answer
Enter the number of HOURS PER WEEK you would expect the student to work with you doing research.
Your answer
Enter the HOURLY WAGE you would like to pay the student to work with you doing research.
Your answer
Enter the TOTAL WAGES you would like to pay the student to work with you doing research (WEEKS x HOURS x WAGE).
Your answer
For Unpaid Internship (if applicable)
Enter the number of WEEKS the student will be doing an unpaid internship.
Your answer
Enter the number of HOURS PER WEEK you'd like the student to be paid with experiential learning funds while the student will be doing an unpaid internship.
Your answer
Enter the HOURLY WAGE you would like the student to be paid with experiential learning funds while doing this unpaid internship.
Your answer
Enter the TOTAL WAGES you would like the student to be paid with experiential learning funds while doing this unpaid internship. (WEEKS x HOURS x WAGE).
Your answer
Tuition: Enter the cost of tuition for the time period covering the unpaid internship.
Your answer
For Student Teaching (if applicable)
Total cost that would be helpful for the student to replace "lost" wages while doing unpaid student teaching.
Your answer
For Study Abroad/Internship/Field Study (if applicable)
Program cost
Your answer
Tuition (if not already included in the program cost)
Your answer
Housing/Lodging (if not already included in the program cost)
Your answer
Health Insurance (if not already included in the program cost, and if required)
Your answer
Airfare (if not already included in the program cost)
Your answer
Meals (if not already included in the program cost)
Your answer
Public transit (if not already included in the program cost)
Your answer
Passport/Visa application cost
Your answer
Personal supplies
Your answer
Research Costs
Your answer
Research Costs Explanation (if applicable)
Your answer
Mileage Reimbursement (Standard Rate=Miles driven x .545) OR (Fuel Only=Miles driven x .19)
Your answer
Miscellaneous Costs
Your answer
Miscellaneous Costs Explanation (if applicable)
Your answer
Total Cost
Total all Costs for Experiential Learning
Your answer
How accurate are the costs entered in the applicable categories above?
Please explain above answer if needed
Your answer
Financial Resources
If known, what are the student's expected financial resources for this opportunity? (scholarships, financial aid, personal income and savings, support from family, support from faculty mentor, etc.)
Your answer
Total Financial Support Needed = Total Cost - Financial Resources
Subtracting the student's expected financial resources (if known) from the total cost of the experiential learning, how much financial support would this student need in order to have the desired experience listed above? (If financial resources are unknown, assume zero.)
Your answer
If the student does not receive the full amount you are requesting for this student, would he/she still be able to have this experience? *
If this experience is funded fully or partially, based on your student's need, by what date does this student need the funds uploaded to his/her student account or to your 20-account if for a mentoring experience?
MM
/
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YYYY
Other Comments?
Your answer
Submission
We do not have a deadline for requesting experiential learning funds as this will be ongoing until the funds are used for the year. When ready, please submit this form below AND email dianne_tice@byu.edu to let her know that you have submitted an application for review.
Submit
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