Application date / /  (mm/dd/yyyy)

Name

Mailing address

City

State

    Postal code

E-mail

Phone

Applicant ministerial status:
Ordained clergy   
Licensed clergy

Congregation name

Congregation location
(City, State)

Congregation phone

Highest educational degree received:
            Year (yyyy)

Please provide the following information for which continuing education scholarship is requested.

Event/program name

Event/program date

(mm/dd/yyyy)

Event/program location

Sponsoring institution

Event/program contact person name

Event/program contact person phone

Will this program apply toward an academic degree?
Yes  No
If yes, what degree?

Anticipated completion date: (mm/dd/yyyy)

Date and nature of most recent continuing education program:

Have you ever received a continuing education grant from Disciples Home Missions?
Yes   No

If yes, list each year that you have received a DHM grant, beginning with the most recent.

Total family income (including housing allowance or 15% of base salary, if parsonage is provided):

Number of exemptions reported for income tax purposes

Additional information bearing on financial need:

Cost of the continuing education program (mark 0 if no cost):

Attention: please use numbers signifying monetary amounts to answer the remaining questions. All questions must be answered, even if the answer is 0. Total cost amounts must match related cost and investment/grant-request figures to be considered for any DHM award.

Tuition or registration fees to be paid to sponsoring institution or organization

Additional cost for travel, if any

Additional cost for lodging, if any

Additional cost for meals, if any

Other additional cost, if any

  Total cost

Share of cost by continuing education partners:

Amount applicant will invest

Amount congregation or other church related employer will invest

Amount Region will invest (as substantiated by completed section III)

Amount of scholarship sponsoring institution or organization will invest

Amount requested of Disciples Home Missions

Total cost

Updates

Do you wish to receive updates via mail from DHM, including the Home Mission Advocate?
Yes N o