Your Name

School or Institution

Full Address for School or Institution

Your Email Address

Briefly describe your financial need for a scholarship - Do you qualify as a Title I School?

How many students do you expect to reach with the Power Up, Speak Out! toolkit?

Please list your top three concerns or issues that you believe the Power Up, Speak Out! curriculum will help address at your school / institution:

Are you willing to participate in pre- and post testing if you are awarded a scholarship? (Approximate time commitment = 2 hours) Are you willing to participate in pre- and post testing if you are awarded a scholarship? (Approximate time commitment = 2 hours) Yes No

Are you interested in facilitated trainings provided in-person or virtually? (For student or educator audiences and tailored for your specific needs) Are you interested in facilitated trainings provided in-person or virtually? (For student or educator audiences and tailored for your specific needs) Yes No