Application Cover Sheet
( Please Print )

Date Submitted: ___________________________

Name:_______________________________________________________

Street Address:_______________________________________________

City/State/Country/Mail Code: ___________________________________

Telephone: (day)__________________(evening) ________________

E - mail: _________________________________________________

Date of Birth: _____________________________________________

Proposed Dates of Travel: __________________________________

Point of Departure: ________________________________________

Destination: __________________ ___________________________

Amount Requested: ______________________

How did you hear about us?_________________________________

___________________________________________________________

If awarded a grant, I agree to submit documentation of my journey to A Coracle Foundation. This may take the form of a journal, artwork, photographs, or a combination thereof. Any published works must credit A Coracle Foundation. I understand that if I am awarded, my grant is to be used for transportation only.

Signature________________________________________________

Date____________________________________________________