Scholarship Application
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Additional Information
What group/event are you registering for?
*
Campus
*
Cedar Falls
Decorah
Fort Dodge
Grinnell
Independence
New Hampton
Osage
How much are you able to put toward this group/event?
Dollar Amount
How much are you able to put toward this class/event?
$25
$40
$50
$60
$75
$85
$95
$100
Please share why you'd like to attend this class/event, plus any additional information you'd like to give us.
*
Submit
Should be Empty: