Annual Coalition Membership Meeting: October 11-13, 2022

Registration/Travel Scholarship Request Form

Meeting and Lodging Location:

DoubleTree Hilton

2540 North Cleveland Avenue, Roseville, MN. 55113

651-636-4567

*Limited Scholarships Available

October 11: 9:00a-5:00p

October 12: 9:00a-5:00p

October 13: 9:00a-12:00p

*Masks, social distancing, and vaccinations are encouraged*

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* 1. Contact Information

Name

Address

Org or Role in Community

Tribal Affiliation

Email Address

Phone Number

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* 2. I am:

Registering to attend in person, but I am covering all of my own costs

Requesting a Travel Scholarship (see options below)

* Please note that Scholarship recipients are responsible for cancelations

Other (please specify)

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* 3. Please indicate scholarship needs

Hotel Fee @ $148/Night

Mileage @ $.625/Mile for driver (Copy of Google Map, Valid Drivers license and Insurance required)

Hotel Fee AND Mileage

My Organization is covering my travel costs

I am covering my own travel costs

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* 4. If requesting a Scholarship: Please reserve my room for:

Only the night of Mon. October 10, 2022

Only the night of Tues. October 11, 2022

Only the night of Wed. October 12, 2022

All three nights, checking in Mon. October 10, 2022 after 4pm, checking out Thurs. October 13, 2022 by 11am

Other (please specify)

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* 5. Will you be lodging with one or more persons?

Yes

Please list room mate(s):

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* 6. Will you be carpooling?

Yes

Please list primary driver:

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* 7. Are you a service provider or Advocate? Please list:

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* 8. Are you a survivor of sexual violence? (Please answer only if comfortable)

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* 9. Ability Accommodations/Restrictions (please list):

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* 10. Additional Comments

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* 11. Please provide a brief paragraph about why you are requesting a scholarship and how attending this gathering will benefit you, your family, your program, or your community.