Scholarship Application Form

Financial Scholarship Request
Name of Participant*

First NameLast Name
Male / Female*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
What program/camps are you requesting a scholarship?

AgriVenture Farm Camp
To be Completed by Parent / Guardian
Please make a brief statement describing why your child is in need of financial assistance. *
To be Completed by Parent / Guardian
Please list ways your child is or is planning on raising a portion of their participant fees.
What is your occupation / job title? *
What is spouse's occupation? *

What is the combined/total annual household income: Check the appropriate box. *

	Under $20,000	$20,000-$30,000	$30,000-$40,000	Over $40,000
Income

The amount of assistance is based off a rolling tier.

The items listed below are to be transferred from your 1040: (Includes spouse's information, if applicable).
Number of Dependents*
Line 6C on 1040, Line 5on 1040 EZ or Line 6C on 1040A.
Adjusted Gross Income*
Line 37 on 1040, Line 4 on 1040 EZ or Line 21 on 1040 A.
Total Income*
Line 22 on 1040 or Line 15 on 1040 A.
List Special Circumstances. (If Any)
Do you have other children attending camp/program this year?*

YesNo
By signing this document, I agree that the information is accurate.
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Signature*

Clear
References

Based on the quantity applications received, references may be requested. You will be contacted if references are needed. Examples of references may include Teacher, School Administrator, Scout Leader, Pastor, etc.
Please Note: Scholarships/Financial Assistance is not guaranteed. It will be determined based on the viability of your application and may not cover all activitiy expenses. Assistance will be given based on the availability of funds and level of need. We encourage participants to engage in raising funds for their desired camp or activity, to help offset costs.

This application is confidential. The information on the form will not be disseminated.

Applications for camps and programs will be held until notification of financial assistance is made. Applicants will be made made aware of the award amount within 2-4 weeks of appying.
Should be Empty:

Financial Scholarship Request

To be Completed by Parent / Guardian