OFFICE USE ONLY:   APP. # _______ REGION: ______ AWARD: ______________

[Application Form]      [Budget of Materials]


WVATS Mini-grant Opportunity Application Form

Due August 15, 2008

Return completed form to:
Jamie L. Hayhurst-Marshall
WVATS Assistive Technology Coordinator
959 Hartman Run Road
Morgantown, WV 26505
Email: jhayhurst@hsc.wvu.edu
Or fax to: 304-293-7294

APPLICANT INFORMATION

Applicant Name: __________________________
Address: _________________________________
City: _________________________________
State: _____   Zip: ____________
Phone: ______________   Fax: ____________
Email: _________________________

SCHOOL INFORMATION

School Name: _____________________________
County: ______________
Address: __________________________________
City: ____________________________
State: _____   Zip: ____________
Phone: _____________   Fax: ______________
Principal Name: ___________________________

PROJECT INFORMATION
(You may attach computer generated answers, but please provide original signatures on this application.)

Name of Project:

_______________________________________


Grade levels of participating student(s):

_______________________________________

Subject:

__________________________________________


Number involved:

Students __________      Teachers _________


Provide a description of the project:







List the goals and objectives of the project
(goals and objectives should be concrete and measurable):







Describe how the project will be implemented, outlining events that will take place:







Describe the expected outcomes of this project:







Describe how this program will be evaluated:










____________________________     __________

Applicant Signature                                 Date


____________________________     _____________

School/RESA Administrator Signature           Date



WVATS Mini-grant Opportunity

Budget Information October 1, 2008 through May 15, 2009

Please provide a detailed itemized budget of materials for which you are requesting funding for your project

LINE ITEM                                                     BUDGET

Equipment




Supplies




Communication




General Expenses




Other, specify




Total


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