Please complete the following questions as fully as possible. Mail the completed form to:

Questions about grants may be directed to Mary Ross, Coordinator of Continuing Education.

Name of program or project: ____________________________________________
________________________________________________________________________
________________________________________________________________________

Admission cost:	WLA member:________	Non-member: _________
(note - a distinction between member and non-member fees is required)

Date(s) event to be held: ______________________________________________

Location(s): ___________________________________________________________

Sponsor of program (if program is to be co-sponsored, please describe):
________________________________________________________________________
________________________________________________________________________

Contact person:
	Name: __________________________________________________________
	Address: _______________________________________________________
	________________________________________________________________
	Telephone:___________________________ Fax: _____________________
	Email: _________________________________________________________

Purpose or summary of presentation: ____________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Name and background/qualifications of presenter(s): ____________________
________________________________________________________________________
________________________________________________________________________

Needs assessment conducted:
	___ CE Committee Survey
	___ Survey of WLA membership
	___ Other (please describe) ____________________________________
	________________________________________________________________

Who is the primary audience? ___________________________________________
________________________________________________________________________

Estimated number of participants: ______________________________________

What will participants be expected to learn? ___________________________
________________________________________________________________________
________________________________________________________________________

How will the program be evaluated?
	___ CE Committee Evaluation Form
	___ Test
	___ Narrative comments
	___ Other (please describe) ____________________________________
	________________________________________________________________

------------------------------------------------------------------------
BUDGET:

     INCOME:   Registration fees - WLA Members _______
                                 - Non Members _______

               Estimated number of participants - maximum _____
                                                - minimun _____
          
               *Note: Please estimate income based on minimum number of
                participants. Budget registration fees accordingly.

               *Remember to include a $2 per registrant charge to cover
                ADA accommodation contingencies.


     EXPENSES: Please outline expenses below. Indicate with an asterisk
               (*) items to be paid from WLA CE funds. Indicate source(s)
               of other funding where applicable.

               Advertising: $________
               (Remember to include estimated costs for printing and
               postage).

               Food and site accommodations: $______
               (Include room and equipment rental fees, costs for
               refreshment breaks as needed)

               Registration and materials costs: $________
               (Include photocopying costs for handouts, evaluation
               forms, agendas, etc.)

               Program: $_______
               (Include fee for presenter(s), air fair and other      
               transportation costs, hotel and per diem.)
          
               Other: $_______
               _________________________________________________________
               _________________________________________________________


     TOTALS:

     Total funds requested (expenses):                    $____________

     Total income expected (based on minimum attendance): $____________

     Note: If expected income does not match or exceed total funds
     requested, please explain (e.g. other funding sources or in-kind
     contributions.