Application for SPICE Grant
Thank you for applying for grant funding through SPICE. Please fill out the form below as completely as possible.
Name of Funding Recipient
School Currently Attending
Parent/Guardian Name (First and Last)
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Have you requested funds from other sources for this service?
Is this service covered in part by insurance? If yes, explain below
How many people are in your household? Include yourself, spouse, and any dependents
How many people in your household attend a tuition-based school? (Grade school, high school or college)
What is your household Adjusted Gross Income for 2021 on IRS for 1040 line 7?
Additional Income not reportable? If yes, please explain below.
Name of Provider for services being requested:
Contact information for provider of services be requested:
Please provide the name of the teacher, doctor, or specialist recommending these services:
Any Additional information you would like to provide for consideration
If you have any questions, please contact Diane Wagner at 314-822-1347 x3008 or email@example.com
Should be Empty: