Name of Education Virtual Program (Please enter program name on the line below):
(Refer to for details on programs.)
Desired Date for Program:
Desired Time of Programs:
Financial Assistance for Distance Learning Programs
Today’s Date Group Name
Address Town State Zip
Grade Level Contact Name
Primary Phone #
Alternate #
Email Address
Total # of Students in-group:
Have you made a reservation? Yes: No:
Reservation Number:
If you are a School, how many students participate in the Federal Free/Reduced Lunch Program? If you are an
organization, how many of the above students receive financial aid from you?
Other Criteria indicating need:
If we cannot wholly subsidize your distance learning program, what is the maximum amount you
can contribute towards the distance learning program cost?
Teacher Signature: Date:
Principals or Executive Director’s Signature (required): Date:
Please Email to:
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