Scholarship Application
Applications and supporting documentation must be submitted by May 31 of each year. Applications and supporting documentation will NOT be accepted after the May 31 deadline. Scholarships will be awarded in early July of each year and announced soon thereafter. The amount of each Kids' Chance of Mississippi Scholarship awarded is decided by the Scholarship Committee; the amount of the scholarship(s) awarded is undetermined at application time.
Student Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone Number
Mobile Phone Number
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Social Security Number
Family Information
Father's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Mother's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Number of Persons Living in Household
How Many are Minor Children?
Injured / Deceased Parent Information
Parent's Name
First Name
Last Name
Parent's Social Security Number
MS Workers' Compensation Claim #
Date of Injury
-
Month
-
Day
Year
Date
Date of Death
-
Month
-
Day
Year
Date
Name of Parent's Employer
Address of Parent's Employer
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employer's Workers' Compensation Insurance Carrier
Claim Adjuster (if known)
Attorney (if Applicable)
Is Your Other Parent / Step-Parent Employed?
Yes
No
Name of Other Parent's Employer
Address of Other Parent's Employer
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Academic Information
Name of High School
Address of High School
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Schools, Colleges or Universities You've Applied to:
Name
Address
Accepted
Plan to Attend
1
2
3
4
5
6
Intended Major / Field of Study
Career Objective
How do You Plan to Finance Your Education (select all that apply):
Grants/Scholarships
Financial Aid
Parental Support
Self / Employment
Personal Loans
Expected Cost per Semester
Will You Be Attending Your School of Choice Regardless of Whether or Not You Receive this Scholarship?
Yes
No
Income from Loans, Grants, Scholarships, Employment, Savings and Family Contributions
Amount
Type
Status
1
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
2
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
3
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
4
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
5
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
6
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
7
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
8
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
9
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
10
Loan
Grant
Scholarship
Employment
Savings
Family Contribution
Applied
Accepted
Denied
Received
Do You Plan to Live at Home or on Campus?
Home
Campus
Do You Plan to Work During the School Year?
Yes
No
Type of Work
Hours Per Week
Rate of Pay
Other Circumstances Which You Feel the Kids' Chance of Mississippi Committee Should Know in Reviewing Your Scholarship Application:
Household Financial Information
Averaged on a Monthly Basis, Please List all Sources of Household INCOME:
Amount
Workers' Compensation Payment
Disability Insurance
Parental Income
State/Federal Financial Assistance (i.e. Welfare)
Child Support Received on Behalf of Children in Same Household
Other Income (if any)
Total Monthly Income
Averaged on a Monthly Basis, Please List all Sources of Household Expense:
Amount
Rent / House Payment
Car Payment
Insurance (Health, Car, and Home)
Utilities (including phone)
Child Support Received on Behalf of Children OUTSIDE the Household
Incidentals (food, gas, clothing, etc.)
Medical Bills (not covered by workers' compensation)
Other (credits cards, etc.)
Total Monthly Expenses
Scholarship Need
Give Your Anticipated Needs for the Upcoming School Year:
Amount
Tuition
Books
Living Expnses
Total Scholarship Need:
Upload Documents
The following documents are needed to complete your application:
Certified Copies of Transcripts from the School You Are Attending or the Last School You Attended (required)
FAFSA Application (optional but preferred)
Financial Aid Award Letter from the School You Will be Attending
Letters of Recommendation (optional)
Current Photograph (required)
Proof that a parent has been found permanently or totally disabled or suffered death from a work related injury. Sufficient evidence of proof includes a death certificate, documentation from parent's employer, workers' compensation insurance carrier, or the Mississippi Workers' Compensation Commission. (required)
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List the Names of All Persons Who Assisted You in Preparing this Application
I certify that the information contained in this Kids' Chance of Mississippi Scholarship Application is true and correct to the best of my knowledge and belief. I hereby apply for a scholarship from Kids' Chance of Mississippi, Inc. and consent for it to be verify the contents of this application. I agree to allow the school, college or university to send a copy of each semester's (or quarter's) grades to Kids' Chance of Mississippi, Inc. It is fully understood that compliance in this matter is necessary for funds to be paid on a timely basis. I further consent for Kids’ Chance of Mississippi, Inc., their agents, employees or designees to contact and verify any information contained in this application through contact with any individual, government, educational institution or other such entity. I further grant permission to Kids’ Chance of America, Inc., Kids’ Chance of Mississippi, Inc. and my college, university or vocational school to use my name and likeness in a photograph in any and all of their publications, including printed and digital publications, for purposes of publicizing the scholarship, my receipt of the scholarship and/or any other lawful purpose without the right to inspect or approve any such publication and without the right to any royalties or further compensation.
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