GRASSROOTS RADIO CONFERENCE 11
July 27-30, 2006  |  Madison, WI

-- CONFERENCE FUNDS REQUEST --

Name: _________________________________________________

Street address: _________________________________________________

City/State/Zip: ______________________________________________

Phone:_____________________________ Email: ___________________________

Organization name: _________________________________________

I am applying for the: (mark one)

____ Solidarity Fund (established to increase ethnic/racial diversity at the conference)

____ Conference Assistance Fund (established for general support for low-income attendees)

I am requesting $_______ from this fund to cover:
         






I am in need of a scholarship because:








REMINDER: To reduce the cost of attending GRC-11, visit http://GrassrootsRadio.info for listings of free homeshares, low-cost hostels, rideshares, public transit, links to low-cost airfare finders, and more.

Also, flights booked less than three weeks prior to the conference are very likely to cost much more.


Please return this request form by email to <GRC11@WORT-FM.ORG>

Or by mail to:
GRC-11 Solidarity Fund Request
c/o WORT-FM
118 S. Bedford St.
Madison, WI  53703

REQUESTS MUST BE RECEIVED NO LATER THAN FRIDAY, JUNE 30 to ensure consideration.
Recipients announced the following week.