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Scholarship Application Astronomical Society of the Pacific 2012 Meeting Tucson, AZ August 4-5, 2012 Please fill out completely (type or print): Name: ___________________________________________ Grade levels taught: _________________ Subjects taught: ____________________________ School: ______________________________________________ City and state of school: ________________________________________________ Name of your supervisor: _________________________________ E-mail (one you check in June and July): _________________________________________ Best mailing address for you in June and July: _____________________________________________________________________ _____________________________________________________________________ In one paragraph (bullet points are OK), explain how attending the ASP meeting will benefit you and your students (include an estimate of the percentage of your students who are Hispanic or Native American): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


Estimated Travel Costs (give details, remember, you will need receipts): Item: _____________________________ estimated cost: ____________ Item: _____________________________ estimated cost: ____________ Item: _____________________________ estimated cost: ____________ Item: _____________________________ estimated cost: ____________ You can request up to $90 in travel cost reimbursement! (TRAVEL subtotal requested): Our part of the $75 Registration Fee Please add the two subtotals: ________ $40.00 TOTAL scholarship amount requested: _______________ (maximum possible $130)

Any additional information you would like the scholarship committee to have: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Your signature below affirms that you understand that you are responsible for $35 of the registration fee, for any travel costs above $90, and for attending the full workshop. ______________________________________ Signature ________________ Date