Scholarship Award Request

Roger Heintz Youth Scholarship

Award Request Form
All requests for scholarship awards needs to include post secondary verification documents. Acceptable documents include: Transcripts, finiancial statements, or enrollment letters. Document must have the name of the accredited institution and the name of the student. If one document does not include both, two documents may be submitted.

Scholarship funds will be mailed to the address listed by recipient below. Please ensure this address is accurate for delivery.
Name

First NameLast Name
Email
example@example.com
Phone Number
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Scholarship Information
Year Scholarship Awarded
Required Attachments
Transcripts, Enrollment Documents, etc...

Cancelof
I agree that all information provided is true and correct to the best of my knolwedge, and any misrepresentation may eliminate me from scholarship consideration. If selected, I agree that my name will be released publicly on ARCHA website & social media.
Applicant's Signature

Clear
Name of Applicant

First NameLast Name
Date Signed by Applicant

MonthDayYear
Date
Should be Empty:

Roger Heintz Youth Scholarship