Community Access Program Application

Scholarship Application Form

Esperanza's Second Chance Sanctuary Community Access Scholarship
If selected, you will be asked for documentation to support the data you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
I. Personal Data:

Tell us about yourself
Full Name*

First NameLast Name
Birthdate:*

MonthDayYear
Mobile No. :*

Area CodePhone Number
E-mail :*
Where the confirmation will be send to
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Optional Informations :

Information regarding gender, ethnic origin and race are optional. The information is requested for post-scholarship report generation only and in no way affects your selection for scholarship awards. However, providing this information may increase your opportunities for scholarships where donors have asked that priority consideration be given to students meeting certain demographic criteria (such as minority status, place of employment, etc.)
Gender:

MaleFemaleTransgenderGender NeutralNon BinaryAgenderPangenderGenderqueerTwo SpiritThird GenderAll of the aboveNone of the aboveOther
Ethnic Origin:

HispanicNon-HispanicNot Indicated
Race? (Choose one or more):

WhiteBlack or African AmericanAsianAmerican Indian or Alaskan Native Hawaiian or Other Pacific IslanderIndigenousRomaOther people of colourOther
Please check veteran status (Check all that apply)

VeteranChild of a VeteranGrandchild of a VeteranSpouse of a VeteranNone of the Above
Are you a public service worker ?

YesNo
Do you make a combined household income of 39,000.00 or less per year?

YesNo
Do you reside in Indio, CA or Desert Hot Springs, CA?

YesNo
Do you recieve any of the following?

SNAPWICHUD - Housing supportLIHEAP- Utility supportCash AidMediCalIEHP
Are you applying on behalf of an organization?*

YESNO
If so what type of organization?

SchoolYouth organizationFamily Resource CenterPsychology/PsychiatryMedicalSchoolHigher EducationAssisted Living/Hospice/Memory Care
Are You Neurodivergent?

YesNo
Are You Disabled?

YesNo
Major Area of Need:
Please indicate what is your major area of need
Tell us about yourself and why you are applying for assistance

0/300
VIII. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
ESPERANZA'S SECOND CHANCE SANCTUARY is committed to equal opportunity in employment and education. ESCS does not discriminate in any program or activity on the basis of race, color, religion, gender, age, national origin, disability, marital status, or any other protected class.
Do you work in K-12 Public Education?

YESNO
Should be Empty:

Scholarship Application Form

I. Personal Data:

VIII. Applicant's E-Signature