ELS Youth Retreat Grant

Youth Director/ Pastor Name

First

Last

Email

Phone

Congregation Name, City, State

Title and Brief Description of Event

Date of Event

Total Youth in Attendance

Total Number of Participants (including leaders)

Total Topic of

Congregations Involved

Devotion/ Study Topic

Total Reimbursement Requested

Please attach receipts. (.pdf or .jpg

Drag & Drop Files, Choose Files to Upload

Attach any pictures of your event. (.jpg)

Drag & Drop Files, Choose Files to Upload

Check payable to (name or church name):

Address

Address Line 1

Address Line 2

City

State

Zip Code