Chapter Information
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Chapter/University Name:
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Mailing Address:
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City:
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State:
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Zip Code:
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Office Phone Number:
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Fax:
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E-mail:
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Web Address:
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Chapter Advisor First Name:
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Chapter Advisor Last Name:
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Chapter Advisor ASHA Account Number:
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Chapter Advisor E-mail:
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Co-Advisor First Name:
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Co-Advisor Last Name:
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Co-Advisor ASHA Account Number:
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Co-Advisor E-mail:
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Chapter President First Name:
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Chapter President Last Name:
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Chapter President NSSLHA Account Number:
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Chapter President E-mail:
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Chapter Vice-President First Name:
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Chapter Vice-President Last Name:
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Chapter Vice-President NSSLHA Account Number:
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Chapter Vice-President E-mail:
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Region (locate your region):*
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Application
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Timeframe to Consider This Application:*
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Has this chapter received this grant in the past?*
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If received in the past, please indicate when (semester and year).
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If awarded, the check should be made payable to:*
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Proposed Name of Project/Conference:*
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Expected Date of Activity (MM/DD/YYYY):*
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Provide a description of the purpose and objective(s) of the project, including how the project addresses NSSLHA student interests and the intended outcomes of the project.*
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Provide a tentative schedule of activities or topics.*
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List other NSSLHA region(s) involved with this project and/or how they will be notified of this activity (if no other regions will be involved, type "none").*
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| Provide the following estimates of project/conference attendance. |
Students (indicate both number and percentage of total):*
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Non-Students and Professionals (number and percentage of total):*
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Total Expected Attendance:*
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Describe how the project will be evaluated (e.g., follow-up questionnaire, individual comments/letters, examination, etc.).*
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List all the previous projects carried out by this NSSLHA chapter and indicate the sources of funding (if no other projects have been completed, type "none").
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| NSSLHA funding should be used as bridge funding for projects. This means that grant funds are awarded only to projects that are not able to meet budget projections. Project budgets that reflect a profit potential will not be funded. |
Describe why you need NSSLHA funding. Provide details on how NSSLHA funds will be used.*
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Specify all the sources of alternate funding and the expected amount from each (e.g., Student Government $300, Lions Club $50, etc.).*
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| Submit a proposed budget for the project including these line items (enter 0 for any unused budget categories). |
Publications/Advertising:*
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Postage/Mailings:*
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Guest Speaker Honorarium:*
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Lodging for Speakers:*
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Meals for Speakers:*
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Transportation for Speakers:*
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Space Rental/Project:*
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Equipment Rentals (projects, sound equipment, etc.):*
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Other Expenses (specify expense and amount):*
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Anticipated Income:*
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Amount Desired From NSSLHA:
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