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* OK Question Title * 1. Contact Information Name Address Org or Role in Community Tribal Affiliation Email Address Phone Number OK Question Title * 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 cancelationsOther (please specify) OK Question Title * 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 OK Question Title * 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) OK Question Title * 5. Will you be lodging with one or more persons? Yes No Please list room mate(s): OK Question Title * 6. Will you be carpooling? Yes No Please list primary driver: OK Question Title * 7. Are you a service provider or Advocate? Please list: OK Question Title * 8. Are you a survivor of sexual violence? (Please answer only if comfortable) OK Question Title * 9. Ability Accommodations/Restrictions (please list): OK Question Title * 10. Additional Comments OK Question Title * 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. OK DONE