FWMSH Little Scholars Program REGISTRATION FORM

FWMSH Little Scholars Program

Registration Form
Student Name *

Last Name Frist Name
Gender *

Female Male
Child's Grade *
Child's Birthday *

Month Day Year
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary email address (if available) for communication from the FWMSH Little Scholars Program staff
email
Parent/Guardian #1 *

Last Name First Name
Day Time Phone Number *

Area Code Phone Number
Home or Cell Number *

Home Cell
Parent/Guardian #2 *

Last Name First Name
Daytime Phone Number *

Area Code Phone Number
Home or Cell Number *

Home Cell
ENROLLMENT FEE

There are three fee levels for enrollment in the FWMSH Little Scholar’s Program– Fort Worth Museum of Science and History members, non-members and the scholarship level. Students whose families are currently enrolled in an official public assistance program (Medicaid, TANF, SNAP, Texas WIC) qualify for a FWMSH Little Scholar’s Program scholarship. Students whose families are not receiving public assistance but whose income meets the eligibility guidelines of Texas WIC (Women, Infants and Children) may be eligible for a Little Scholar’s Program scholarship. To check your household income eligibility guidelines, please access the Texas WIC website at https://texaswic.org/apply. To apply for a FWMSH Little Scholar’s Program Scholarship, please complete the FWMSH Little Scholar’s Program Scholarship application and turn it in with this registration form.

Payment for the FWMSH Little Scholar’s Program at the member and non-member levels may be made in full or in three installments (only with the use of a credit card). The first installment is due with this registration form and the remaining two payments will be automatically charged to the credit card used for the first payment.
The fees listed below are for the fall session of October 5 through December 18, 2020.
Select your payment options *

FWMSH Member 1 payment of $780 FWMSH Member 3 payments of $260 Non-Member 1 payment of $975 Non-Member 3 payments of $325 Applying for Scholarship
FWMSH Member Number
REFUND POLICY

REFUND POLICY Withdrawal requests must be submitted in writing to littlescholars@fwmsh.org. The deadline to submit FWMSH Little Scholars Program withdrawal requests is before October 20th or before November 20th. No refunds will be issued after November 21.
I UNDERSTAND: that a credit card must be used for the first, second and final payments to be able to take advantage of the payment installment plan; the second payment will be automatically charged the week of November 2, 2020 and the third payment will be charged the week od December 1, 2020. I understand it is my responsibility to see that a valid credit card is on file at the time of each payment processing. I also understand the refund policies outlined above should I choose to withdraw my child from the FWMSH Little Scholar’s Program.
PLEASE SIGN HERE TO AUTHORIZE THE 2ND AND 3RD AUTOMATIC FEE CHARGES *

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Credit Card Number *
Credit Card Type *

MC VS AM DM
Expiration Date *
mm/yy
Card Holder's Name *
As it appears on the card
Billing Zipcode *
As it appears on the card
Parent or Guardian's Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

REFUND POLICY