Scholarship Application

Name of person with CHARGE attending

First Name Last Name

Name of person completing application

First Name Last Name

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

How many guest plan to attend in your party?

Scholarship amount applying for

$125$250

Reason for applying

It is a hardship to cover registrationNot on a waiver programOther

On a waiver program (MDCP, DBMD, CLASS) and have contacted my Case-Manger

YesNo

My HHSC Case-Manager's Name

My HHSC Case-Manager's Phone Number

I have contacted my local school district

YesNoNot in school

I have reached out to local organizations ie: Lions Clubs, ect.

YesNo

Please let us know any information you think we should know.

Eligibilty: All current Texas Residents affected with Charge Syndrome or Texas "families" are eligible for scholarships/financial aide providing Texas Chargers, Inc. Board of Directors approves and funding exists.