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Your Information

Email:

Your Name:

Address:

City, State, Zip:

Telephone:

YMCA Information

Your YMCA:

Position:

Four Digit YMCA Association Number:

Indicate current level of YMCA certification:

Full Time or Part Time:

TYPE OF REQUEST

Event start date

Statement for request - enter the training course/event for which you are requesting assistance and the purpose of the training/event. For example, is this a DEI training, part of your professional development plan? Are you applying for LCC credit toward recertification of multi-team or organizational leader certification?

STATEMENT FOR REQUEST

Statement.

Please provide a statement on how the requested assistance will help you/team reach your/team professional development and/or career goals.

IDENTIFICATION OF FUNDS

Individual Registration Fee:

Estimated Travel Expenses:

Estimated Other Expenses:

TOTAL EXPENSES

Total amount your YMCA is paying:

Total Amount of funds being requested from the Alliance Fund (Up to $300):

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