Scholarship Award Application Form

Transcend STEM Scholarship Award Application Form

Transcend STEM Scholarship Award Application Form. This application is for Workforce Development, Employment, and Education Assistance. *PLEASE COMPLETE INFORMATION TO THE BEST OF YOUR KNOWLEDGE*
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

City

Zip Code
City and State
Zip code
Ethnicity
Race
Family Type
Education
Have you served in the military?
Are you disabled?
Health Insurance
Employment
Income(s)
You are REQUIRED to provide income verification through any of the following:
- Pay stubs (last 30 days)
- DIS (last 30 days)
- Employer letter (last 30 days)
- SSI/SSD payment sheet
Proof of income for previous 30 days for ALL incomes received

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Does anyone in your household have any of the following?
Have you or anyone in your household received services through Transcend STEM Education?

Check all the barriers present:

Other
If any barriers were checked, are they indefinite? Please specify which barriers.
Domestic Violence
Expenses:

Car Payment:    $*
Groceries:    $*
Miscellaneous:    $*
Rent:    $*
Car:    $*
Insurance:    $*
Mortgage:    $*
Gasoline:    $*
Maintenance:    $*
Other:    $*
In this section please include ALL MEMBERS of the household for ALL sections. (scroll to the left for complete set of questions.)

Barriers
Income(s)
You are REQUIRED to provide income verification for all people over 18 years old receiving income through any of the following:
- Pay stubs (last 30 days)
- DIS (last 30 days)
- Employer letter (last 30 days)
- SSI/SSD payment sheet
Proof of Income for other household members 18 or older for ALL incomes receive during the last 30 days

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Are you current on your tax returns?
Do you need assistance on getting your taxes completed?
"I, First Name* Last Name* , give Transcend STEM Education consent to release, obtain, and share all pertinent identifying and non-confidential social, medical, and other information about myself that will allow me to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family.
The statements made by me on this consent for are true, correct, and complete to the best of my knowledge"
Applicant signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Self Sufficiency Statement

According to the Community Service Block Grant, "self-sufficiency" is defined as: The applicant needs to be achieving (or working towards) a set goals which will result in greater self-sufficiency and will eliminate some of the causes of that family's poverty. What issues is the applicant facing and the resources the family (or community agencies the family is wokring with) brings to address these issues
Below, please have a written plan toward self-support within your family/household.
Dart Voucher/Bus Pass Program
Are you able to utilize another transit source? *(if you are within 3/4 of a mile of a bus stop, you have a transit source and are ineligible for this program)
Who will be the driver?
What is the primary resource for your transportation?
How will receiving transport assistance help you towards self-sufficiency?
What other resources have you sought/exhausted before seeking the flexible gas voucher program?

Scholarship Program
Have you applied for financial assistance through other means?
What other resources have you exhausted before seeking a scholarship through Transcend STEM?
What college/school do you plan to attend?
What are your employment goals?
Course Desired
Visit transcendstem.org for course catalog
Will this degree/certification/education allow you to provide for yourself?
If you are seeking a GED scholarship, what further education plans (vocational, training, etc.) do you have, if any?

Housing Assistance

(Does not cover mortgages. Contact Homeownership Made Easy for mortgage, closing costs or down payment assistance: 214-770-1252).
According to HUD, chronic homelessness means*:
(1) A homeless individual or head of household with a disability that meets the HUD definition of a disability who
- (a) lives in a place not meant for human habitation, a safe haven, or in an emergency shelter;
  AND
- (b) has been homeless and living in one of these places continuously for at least 12 months OR on at
  least 4 separate occasions in the last 3 years, as long as the combined occasions equal at least 12
  months and each break in homelessness separating the occasions included at least 7 consecutive
  nights of not living in one of the aforementioned places.
  Stays in institutional care facilities for fewer than 90 days will not constitute a break in homelessness
  or other similar facilities.
Are you chronically homeless?
What is your current living situation?
If homeless, in what city did you become homeless?
Where did you sleep last night?
How long have you slept at that place?
What happened to create this housing situation?
Can you turn utilities in YOUR name?
If no, do you owe back utilities? How much?
Do you have any housing barriers that would help prevent acceptance into a new rental? If yes, please explain:
How will you be able to pay your rent/utilities at the end of Transcend STEM assistance?
Have you utilized CEAP for utility assistance?

Authorization to Release Information

Transcend STEM Education Program partners with several organizations to assist families experiencing a housing crisis, unemployment, career changes or needing Education Assistance. The authorization is designed to permit those organizations to share client information inr order to collaborate on services and promote stability.
Client Name

First NameLast Name
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Terms & Conditions
Information to be released: I understand authorized personnel will share client infromtion needed for service, delivery, program eligibility, to track demographic trends, service patterns and the cleint outsomce achieved.

For the purpose of: I understand this is for the purpose of (a) providing coordinated housing, medical, social, psychological, and other service to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordiantion of services to assist individuals and families experincing a crisis, and (d) to identify barriers and service gaps that block the path out of poverty. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed.

Right to revoke: I understand this authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on those disclosures.

Potential Re-Disclosure: I understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations. However, federal confidentiality rules (42 CFR, part 2), prohibit recipients from making any further disclosure of alcohol and substance abuse records unless further disclosure is expressely premitted by written consent of the person to whom they pertain or if disclosure is otherwise permitted by 42 CFR, part 2. The Federal rules restrict any use of information to criminally investigate or prosecute an alcohol or drug-abusive client.
By signing below, I authorize the Transcend STEM Education to share information as it related to my specific needs.
Client Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Copy of Valid ID

Cancelof
Signature
Should be Empty:

Transcend STEM Scholarship Award Application Form

Self Sufficiency Statement

Dart Voucher/Bus Pass Program

Scholarship Program

Housing Assistance

Authorization to Release Information

Terms & Conditions