2022 Kids' Chance of Mississippi Scholarship Application

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.

Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Format: (000) 000-0000.
Mobile Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Social Security Number

Father's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Mother's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Number of Persons Living in Household
How Many are Minor Children?

Parent's Name

First NameLast Name
Parent's Social Security Number
MS Workers' Compensation Claim #
Date of Injury

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Name of Parent's Employer
Address of Parent's Employer

Street Address

Street Address Line 2

CityState

Zip Code
Employer's Workers' Compensation Insurance Carrier
Claim Adjuster (if known)
Attorney (if Applicable)
YesNo
Name of Other Parent's Employer
Address of Other Parent's Employer

Street Address

Street Address Line 2

CityState

Zip Code

Name of High School
Address of High School

Street Address

Street Address Line 2

CityState

Zip Code

Schools, Colleges or Universities You've Applied to:

Rows	Name	Address	Accepted	Plan to Attend
1
2
3
4
5
6

Intended Major / Field of Study
Career Objective
Grants/ScholarshipsFinancial AidParental SupportSelf / EmploymentPersonal Loans
Expected Cost per Semester
YesNo

Income from Loans, Grants, Scholarships, Employment, Savings and Family Contributions

Rows	Amount	Type	Status
1
2
3
4
5
6
7
8
9
10

HomeCampus
YesNo
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:

Averaged on a Monthly Basis, Please List all Sources of Household INCOME:

Rows	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:

Rows	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

Give Your Anticipated Needs for the Upcoming School Year:

Rows	Amount
Tuition
Books
Living Expnses

Total Scholarship Need:

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 AttendingLetters 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)
Upload Files Above

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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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