THE MICHELI CENTER SCHOLARSHIP FUND APPLICATION

THE MICHELI CENTER SCHOLARSHIP FUND APPLICATION
The Micheli Center for Sports Injury Prevention seeks to provide its services to all, regardless of age, sex, ethnic origin, or financial means. To support this goal, we have established The Micheli Center Scholarship Fund, which allows us to offer our services to those who may not otherwise be able to afford it.

The Micheli Center scholarship applications will be reviewed by management to determine the financial need of each applicant. Fees and dues will be reduced according to each applicant’s need and the availability of funds. Scholarship recipients will be required to reapply on an annual basis.
Required Documents:
1. Copy of previous year’s Form 1040 (US Individual Income Tax Return) if federal taxes were filed.

2. Copy of last two (2) employment pay stubs or bank statement showing automatic monthly deposit.

3. Copy of social security checks, disability checks, or copy of bank statement showing amount of automatic monthly deposit if applicable.

4. Copy of unemployment check, incoming child support, incoming alimony payment, or copy of bank statement showing amount of automatic monthly deposit.

5. Copy of rent assistance, ADC, food stamps, or other forms of assistance.

6. Documentation for any other regular incoming funds if applicable.

Note: Staff review of applications may take up to five (5) working days from the date completed materials are received from the applicant.
The Micheli Center Scholarship Fund Application
Applicant name: *
DOB: *

Month Day Year
Legal guardian (if under 18): *
Home address:
Home Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
City: *
State: *
Zip: *
Home phone: *
Home Phone Number: *

Area Code Phone Number
Cell phone: *
Cell Phone Number: *

Area Code Phone Number
Email address: *
example@example.com
Total monthly household income: *
Number of children in household: *
Applying for (check all that apply): *

Injury prevention evaluation Membership Specialty classes/programs
Preferred location: *

Waltham Norwood Either
Please state why you are in need of a scholarship: *
Please state why you are in need of a scholarship. *
Copy of previous year's Form 1040 (US Individual Income Tax Return) if federal taxes were filed.

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Copy (1 of 2) employment pay stubs or bank statement showing automatic monthly deposit.

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Cancel of
Copy (2 of 2) employment pay stubs or bank statement showing automatic monthly deposit.

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Cancel of
Copy of social security checks, disability checks, or copy of bank statement showing amount of automatic monthly deposit if applicable.

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Cancel of
Copy of unemployment check, incoming child support, incoming alimony payment, or copy of bank statement showing amount of automatic monthly deposit.

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Cancel of
Copy of rent assistance, ADC, food stamps, or other forms of assistance.

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Cancel of
Documentation for any other regular incoming funds if applicable.

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Cancel of
Documentation for any other regular incoming funds if applicable.

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Cancel of
I understand that the Micheli Center for Sports Injury Prevention Scholarship Program is designed to assist the youth, adults, and families who would otherwise be unable to participate or who have a particular need for The Micheli Center programs. I agree to notify The Micheli Center of any change in my income or ability to pay. I am aware that assistance funds are awarded for a maximum of one year, after which time it is my responsibility to reapply. I understand that The Micheli Center scholarships and amount awarded are subject to review at any time. I understand that by signing this form I am authorizing The Micheli Center to obtain credit information. All information is subject to verification.
Applicant or legal guardian signature: *

Clear
Date: *

Month Day Year
Date
Please verify that you are human *
FOR OFFICE USE ONLY
RECEIVED BY:
DATE:

Month Day Year
Date
YES
% FAMILY RESPONSIBLE FOR:
EFFECTIVE DATE:

Month Day Year
Date
END DATE (1 year from effective date):
Should be Empty:

THE MICHELI CENTER SCHOLARSHIP FUND APPLICATION

Required Documents:

The Micheli Center Scholarship Fund Application

FOR OFFICE USE ONLY