Norm Pippin mental health fund

In honor and in memory of WBLAS principal Norm Pippin and his wife Norma, the Norm Pippin Mental Health Fund was created. To request funds (staff only), please fill out the request form below. The purpose of the Norm Pippin Mental Health Fund is to provide a permanent endowment which will be used to support Independent School District 624 social workers, psychologists, nurses, and principals to assist students who have financial needs that prevent them from fully participating in the educational process due to their mental health needs.

Each year (September through July), $1,200 will be awarded ($200 maximum per student). Applications for funds will be accepted until the funds have been depleted for the academic year.

NORM PIPPIN Mental Health Fund - REQUEST FORM

This form is to be used only by Independent School District 624 principals, psychologists, social workers, nurses and/or school counselors.

Today's Date

MM

DD

YYYY

Name of District Staff submitting the request

First Name

Last Name

Building

Email

Phone Number

(###)

###

####

Student's Initials

Amount Requested

($200 Maximum)

$

By what date do you need these funds?

MM

DD

YYYY

Explain what the funds will be used for.

Is there a plan for sustainability?

State what other resources have been researched in this request (ie: within the school district, the state, the government) and the status of each.

Make check payable to:

(Vendor Name)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Signature

*Required Field