Donation Request

Eligibility Criteria: Must be an enrolled VOS Tribal member affiliated in a healthy activity that promotes healthy lifestyle choices; extracurricular activities; programs; sports teams; fundraisers for schools, etc. Please reach out to VOS staff to clarify if you have questions on eligibility. Up to $250 per enrolled member can be applied on behalf of the member toward the activity. Tribal Wellness is specific to individual support for wellness activities. Please use that form for individual requests; this donation request is ONLY to provide fundraising support for activities. Please reach out to staff for specific questions and criteria.

Name

First Name

Last Name

Enrollment #

Phone

(###)

###

####

Please explain activity

Include program/activity affiliation, geographic location and timeframe of activity

Amount Requesting

Up to $250

Please provide Information for the Check

Name for the check to be made out to; address to include on the check and to USPS Mail, if check pickup is requested, must be approved and discussed with the Tribal Coordinator

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is there a deadline for fundraising?

Date

YYYY

SIGNED BY

First Name

Last Name