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* 1. Name of School:

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* 2. School Address:

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* 3. School District:

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* 4. Teacher Name:

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* 5. Contact Email:

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* 6. Contact Phone Number:

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* 7. Please list, by preference, 3 date and time options you would like to request for a field trip. Field trips are available Tuesday-Friday 9:30-2:00 and typically last 2 hours long.

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* 8. What percentage of your school qualifies for free and reduced lunch?

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* 9. How many students are you requesting to be covered under this scholarship?

This scholarship will cover the admission costs of every student, as well as chaperones at a 10:1 ratio. Extra chaperones over this ratio are welcome but will cost $5 each. 

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* 10. What grade are the students in?

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* 11. Will your school require an additional scholarship to cover transportation funds? (Transportation funds are limited and we may only be able to offer partial transportation funding. If yes, please email your districts bus rate or a quote from your bus company to info@hwstl.org)

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* 12. Please tell us why you are applying for scholarship funding and why you qualify for assistance.

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* 13. If selected to receive a scholarship, would you be willing to administer a student pre-test and post-test to help HealthWorks! evaluate their programming?

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* 14. Is your school a Little Bit partner?

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