Needs Request (Ages 18-23)

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*

Young Adults First Name*

Young Adult's Last Name*

Young Adult's Age*

Youth's Gender (optional)

Young Adult's Phone Number*

Format: (000) 000-0000.

Young Adult's Email*

example@example.com

Person Requesting Funds*

Person Requesting Funds Phone Number*

Format: (000) 000-0000.

Relationship to Young Adult*

Case Manager's Name (First & Last Name)*

Case Manger Email*

example@example.com

Case Manger Phone Number*

Format: (000) 000-0000.

School Equipment - Monitor, Keyboards, etc. Communication (Phone Card)Apartment Application Fees Housing ExpensesTransportation Assistance (Bicycle or Electric Scooter Purchase)Home Kits-Paper Goods, Toiletries, Cleaning SuppliesTravel for Family Reunion (Two times a year and up to $300)Driving lessons and car to obtain license (driving permit required)Other

Request Description*

Contact Person at Venue (first and last name)*

If approved makes checks available*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Venue Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Program Venue/Housing Email*

example@example.com

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

File Upload*