Move to Amend Leadership Summit 2019 Scholarship Application
We are honored to acknowledge that the Program on Corporations Law & Democracy provided $2,500 for a "Richard Grossman and Ward Morehouse Memorial Scholarship Fund" for the 2018 Leadership Summit.

Please complete and submit this form by midnight Pacific time on April 1, 2019.

We will do our very best to meet all scholarship requests, but cannot guarantee the full amount. Scholarship requests that include your commitment to match Move to Amend national scholarship funds with your local fundraising have a better chance of being met. Please note that scholarship recipients must pay a minimum of $100 towards room and board - this fee can be fundraised locally by affiliate and/or scholarship recipient.

Email address *
Personal Info
Move to Amend Affiliate Name (or your connection to MTA if not affiliated) *
Your full name *
Please use the name we should use when writing out a check.
Affiliate City & State *
Your preferred telephone # *
Your preferred email *
Your home mailing address *
General Questions
What is your primary role with Move to Amend/your MTA affiliate (also indicate formal or informal)? *
How long have you been an active volunteer with Move to Amend (anywhere in the country)? *
Including you, how many people from your affiliate are registering for the Leadership Summit? *
What do you most hope to do, learn, shift - thanks to your Leadership Summit participation? *
Demographics (check all that apply) *
What are your primary reasons for needing a scholarship [elder living on fixed income, low-paid activist or low-wage worker, student, etc.]? *
How will you make sure your affiliate benefits from your participation at the Summit? *
Sharing/applying what you learned, sharing/following up with new relationships, etc.
Will you be participating in the Monday Washington, D.C. Congressional Lobby Day? *
Scholarship Request Breakdown
EXPENSE: Travel to/from Washington D.C. (air, rail, car) *
EXPENSE: Local transportation (to/from airport/station to Trinity University) *
EXPENSE: Room & Board* (Enter $440) *
* Room and Board: three nights lodging (Friday, Saturday, Sunday) in double (2 people) room in Trinity University Dorms, plus all meals (Saturday breakfast through Monday lunch).
EXPENSE: Share of conference expenses (Enter $130) *
EXPENSE: Other (please specify type and amount) *
SUBTOTAL: Expenses *
LESS: The direct contribution you will make at registration (min $150) *
LESS: Additional amount you will raise funds for locally *
SUBTOTAL: Your Contribution *
TOTAL: Scholarship amount requested *
expenses less your contribution
How do you need to be paid? *
Never submit passwords through Google Forms.
This form was created inside of Move to Amend Coalition. - Terms of Service