SEN Power Shift Scholarship Form

**NOTE: WE HAVE GIVEN OUT ALL OF OUR SCHOLARSHIPS & WE ARE NOT ACCEPTING ANY MORE APPLICATIONS**

apply here for scholarships from the Southern Energy Network to attend Power Shift 2009 ( http://www.powershift09.org ). We have limited funds, but we plan on offering ten $50 scholarships for Power Shift. We will review applications on February 5th and on a rolling basis after that until we disburse all of our funds. Questions? contact: powershift[at]climateaction.net

* Required

First Name *

Last Name *

Email address *

Phone *

Address (line 1) *

Address (line 2)

City *

State *

Zipcode *

if there is a date when this address will not be your address anymore, what is it?

School and/or Organization Affiliation (if you have one)

Ethnicity optional, enter the ethnicity(s) that you identify most with

what is your past background with the Southern Energy Network and/or local/regional organizing for a clean energy future? *

why are you excited about going to Power Shift? and how do you think Power Shift will amplify or affect your local efforts? *

how much fundraising have you done/do you plant to do for this? *

How do you plan on getting to Power Shift? * where will you be coming from & how? car by yourself, carpool w/ X people, chartered bus, greyhound, train, plane or other.