Needs Request (Ages 1-17)

YesNo

Tutoring Club of Centennial / Providence • 6710 North Hualapai Way, Suite 145 • Las Vegas Nevada 89149Tutoring Club of North Las Vegas • 6120 North Decatur Boulevard, #102 • North Las Vegas Nevada 89031Tutoring Club of Rhodes Ranch / Mountain’s Edge • 7315 South Rainbow Boulevard, Suite 120 • Las Vegas Nevada 89113Tutoring Club of Henderson / Green Valley • 2213 North Green Valley Parkway • Henderson Nevada 89014Tutoring Club of Anthem • 11241 South Eastern Avenue• Henderson Nevada 89052

Date of Request*

Date

Request Date Deadline*

Date

Amount of Request*

Youth's First Name*

Youth's Last Name*

Child Identification/Unity Number*

Youth's Age*

Youth's Gender*

Person Requesting Funds*

Person Requesting Funds Phone Number*

Relationship to Youth*

Caregiver/Foster Person (First & Last Name)*

Caregiver/Foster Person Email*

example@example.com

Caregiver/Foster Person Phone Number*

Case Manager Name (First & Last Name)*

Case Manger Email*

example@example.com

Case Manger Phone Number*

Sports- Football, Baseball, Swimming, Matinal Arts, Soccer, Basketball, etc. Helmets,Specility Camps-Summer Camps, STEM Camps, Winter CampsLessons- Art, Music, Dance, Gymnastics, Horseback RidingSchool Activities -Prom, Sports Uniform/Gear, School and Leadership TripsTravel Flight Assistance for reunification with family out-of-stateMedical and Dental (Not Provided by Medicaid) - Braces, Walking Devices, HelmetsDriving lessons and car to obtain license (driving permit required)Other

Request Description*

Venue Contact Person (First & Last Name)*

Venue Phone Number*

Please enter a valid phone number.

If approved, makes checks payable to:*

Program Venue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Program Venue Email*

example@example.com

You MUST upload Proof of Cost/Invoice of Activity. NOTE - we cannot process request without the Proof of Cost/Invoice.

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