NAYDO

NAYDO Financial Assistance Application

General Information

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Name


First Name	Last Name

Are you a:

Select one

Staff
Volunteer

Current NAYDO Member? (contact info@naydo.org if in need of membership assistance)

Select one

Yes
No

YMCA Position Title:

How Long Have You Been In The Position?

YMCA Association Name:

Branch Name (if applicable):

Address


Address

Address Line 2

City	State	Zip Code

Phone

Phone Number

Cell:

Phone Number

Fax:

Phone Number

Email Address

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Types of Assistance: Check type(s) that would be most helpful:

Select all that apply

Registration Fee: All financial assistance is awarded at the October 31st rates for staff ($495) and volunteers ($465). It is applied internally.
Hotel Assistance: With tax included for 3 nights hotel assistance the cost for single or double room is $700. Your room will be paid direct by NAYDO and will be at the Omni William Penn. Additional nights can be added at your own expense.
Travel Assistance: Handled as a grant for a specific amount (usually in $500 range)and is presented in the form of a check which you sign for when you check in at the Registration/Information Center onsite.

Total Amount Requested: $

Provide a brief summary of your need:

To complete the process for financial assistance, read and sign below confirming that you understand the following steps:

• I have submitted to the NAYDO Office a copy of the conference registration form with no payment and indicated on the form that I have applied for assistance. Because of no payment this cannot be done online. Email to maryzoller@aol.com or fax to 504-464-6718.• I understand I will be notified by email in December 2011 of the status of my application and will need to confirm acceptance by email.• As a recipient I will be expected to submit an email letter within 30 days of the conference summarizing what I have learned at the conference and what steps I will be taking to implement that information at my YMCA.• By signing below I am authorizing use of my comments in NAYDO promotional pieces including eblasts, web site, brochure, the Developments newsletter and other applicable communications.• If I do not receive the financial assistance, I will have two choices by the January 31, 2012 registration deadline: to pay the registration fee at the Oct. 31 rate or cancel the registration with no financial obligation.

Applicant Name: *

Applicant's Signature *

Select all that apply

By clicking this box, I agree that this will act as my digital signature.

Supervisor's Name *

Supervisor's Signature *

Select all that apply

By clicking this box, I agree that this will act as my digital signature.

Supervisor's Phone: *

Phone Number

Supervisor's Email: *

Email Address

I verify that the above applicant needs financial assistance to pay for the 2012 NAYDO Conference expenses; our YMCA does not have sufficient resources for that purpose.

CEO Name *

CEO Signature: *

Select all that apply

By clicking this box, I agree that this will act as my digital signature.

CEO Phone: *

Phone Number

CEO Email: *

Email Address

* required

NAYDO

NAYDO Financial Assistance Application

Current Support Campaign Raised:

To complete the process for financial assistance, read and sign below confirming that you understand the following steps: