Scholarship Request

Scholarship Request

Colchester Youth and Social Services
All applications require household income documents to be submitted. Applications are approved on a sliding scale based on the total monthly household income. Once all the documentation is received, you will receive a letter with your approval or denial. If you are approved, you will have a discount code sent to you with the percentage off you will receive. This code will be used during registration.
Parent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Date of Birth*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Household Size*

Household Info (please include ALL adult household members) Please include income source for the last 4 weeks (Income sources: Employment, Unemployment, SSI/SSD, Child Support, Etc.)*

	Name	Relationship to participant	Source of Income	Income Amount
Parent/legal guardian
Additional Household Member
Additional Household Member

Child Information *

	Child Name	Child DOB/AGE	Child Grade	School
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6

Please submit documentation of income source for the last 4 weeks (Income sources: Employment, Unemployment, SSI/SSD, Child Support, Etc.) *

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I verify with the submission of this form that the above information is true to the best of my knowledge. I understand that all scholarships are not guaranteed and are donation based. I will submit required documentation to the Youth and Social Services office within 7 days of submission. I verify our household resides in the Town of Colchester. If you have any questions, please call the Youth and Social Services Department at (860)537-7255!
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