Travel Scholarship Application
“Just Elders” Gathering
April 25-26, 2017
(2 p.m. Tuesday through 4 p.m. Wednesday)
The Cenacle Retreat Center, Chicago IL
Each participant pays the retreat registration fee and their own travel expenses. A limited number of travel scholarships are available, on a first-come, first-served basis (fill out the application below.) Those flying must arrange their own ground transportation to and from the airport.
Event Registration Form
(Registration Closes April 11, 2017)
Complete and return this form by conventional mail to:
Rev. Dennis Jacobsen, 2225 W. Skyline Road, Glendale, WI 53209
Enclose a check, based on single or shared room request (see below), made out to Just Elders.
YOU ARE NOT REGISTERED UNLESS FULL PAYMENT ACCOMPANIES THIS FORM.
Street Address: ____________________________ City:_______________________ State:______ Zip:__________
Telephone(s): _______________________ (h)_______________________ (w) _______________________ (c)
Room preference (rates include meals during the event):
- Private (single) room rate: $118.50
- Shared (double) room rate: $95.50
Name your roommate ____________________________ or be assigned a roommate.
(Rooms at the Cenacle are available for one night only, Tuesday, April 25th.)
Special Needs (dietary or otherwise):
Name of emergency contact:______________________________________________
Their relationship to you:____________________ Their phone number: ___________________
Application for Travel Scholarship
I am requesting assistance to help cover my travel expenses. I estimate that my travel for the event will cost approximately $_________. The amount that I am requesting for assistance is:
You will be informed ahead of time whether you will be awarded a travel scholarship. Those funds will be awarded after the event, as reimbursement is to recipients who actually attend. You will need to provide a copy of your travel itinerary prior to receiving your reimbursement. If scholarship funds are depleted before your application is received, and you are not able to come because of travel costs, your event registration will be refunded, upon written request received before the close of registration, which is April 11.