Scholarship Application
Please complete the following information.
Applicant Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Current Class day and time (n/a if not assigned)
Name of Instructor (n/a if not assigned)
Request
Full tuition is $37 per lesson (your monthly tuition varies by class weekday) Tell us the portion of the full tuition you are requesting. Example: I am requesting a scholarship of $18.50. I will provide the remainder of $18.50.
I am requesting a scholarship of
*
I will provide the remainder of:
*
Indicate your understanding of each statement by initialing each line:
I understand that my portion of the tuition is due by the first day of each month. I can pay my portion of the tuition via check, credit card, online through Healing Reins’ through “click to pay” in my monthly invoice.
*
I will acknowledge my appreciation to sponsors of the program by writing two thank you notes a year. I will give the thank you notes to the Program Administrator by July 1 and December 1 each year.
*
I understand that if at any time I am eligible for a credit/refund, this credit/refund will first be applied to my awarded scholarship amount. Any remaining credit/refund will be applied to my account.
*
I understand that this scholarship can be withdrawn if my portion of my tuition is not paid in full by the first of the month (payment due date).
*
I understand that this scholarship can be withdrawn if I have two or more unexcused absences for lessons in a six month period.
*
I understand that participants using scholarship funds are allowed two absences with prior notification, in any two month period. Any additional absences will be charged at full price unless a medical leave of absence is verified by a doctor’s note.
*
I understand that if this scholarship is withdrawn for any reason, I will not be eligible for a future scholarship.
*
If I become able to increase my paid portion of the tuition fee, I will notify the Program Administrator to decrease my scholarship amount.
*
I am requesting financial assistance for the following reason(s): .
*
I hope to no longer require financial assistance as of: .
*
I understand and agree to the above in requesting a scholarship:
Signature of Participant (if participant is a minor, parent or guardian must sign)
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: